Disorders of Venous and Lymphatic Outflow in Cases of Gunshot Wounds of Extremities and Use of Lymphological Therapies

Tumors that compress the retrobulbar optic nerve at a position posterior to the exit of the central retinal vein (CRV) from the optic nerve sheath typically produce progressive optic atrophy without optic disc edema, whereas those anterior to the CRV exit often result in optic disc edema, presumably due to compromised venous outflow with resultant optic disc congestion. There is evidence, however, that more posterior optic nerve compressive tumors may be associated with dilation of the perioptic subarachnoid space (SAS) anterior to the lesion, and chronic optic disc edema may be present. Our report demonstrates long-term clinical and radiographic follow-up of a patient with dilated perioptic SAS and chronic optic disc edema secondary to a presumed optic nerve sheath meningioma. A 54-year-old woman was noted to have optic disc edema in the right eye on routine examination. She reported vague intermittent visual blurring, but the visual acuity and automated perimetry were normal. Over the next 2 months, she developed transient visual obscurations with blackout of vision in the right eye lasting seconds, associated with orthostatic change or rapid head movements. The past medical, surgical, family, allergic, and medication histories were noncontributory. Examination revealed visual acuity of 20/20 in each eye with normal color vision and pupillary responses. The right optic disc showed 1+ edema, without optic atrophy or retinochoroidal venous collateral vessels (Fig. 1). The remainder of the examination was normal. Perimetry was normal. MRI of the orbits revealed thickening and enhancement of the right optic nerve sheath in the posterior orbit and optic canal, consistent with optic nerve sheath meningioma. The perioptic SAS anterior to the tumor was dilated, with increased T2 weighted hyperintensity consistent with cerebrospinal fluid (CSF), with a sharp demarcation at the anterior tumor margin, 12 mm posterior to the globe (Fig. 2).FIG. 1.: Color fundus photographs. Initial evaluation. Right eye (top left) showing optic disc edema without retinochoroidal collateral vessels. Left eye (top right) showing normal optic disc. Follow-up evaluation 4 years later. Right eye (bottom left) continues to show optic disc edema without retinochoroidal collateral vessels. Left eye (bottom right), optic disc remains normal.FIG. 2.: MRI of the orbits. Axial orbital views. T1-weighted image (top left) with fat-suppression and gadolinium administration: The right optic nerve sheath is thickened and enhancing from the optic canal to mid-orbit. A sharp demarcation is present at mid-orbit, anterior to which the perioptic subarachnoid space is dilated to the globe. Axial T2-weighted image (top right) confirms dilation of the subarachnoid space anteriorly on the right with no space visible posteriorly. Coronal orbital views. T1-weighted image through mid-posterior orbit (bottom left) shows thickened and enhancing right optic nerve sheath. T2-weighted image through anterior orbit (bottom right) shows dilated perioptic subarachnoid space on the right.Conservative management with observation was recommended, and the symptoms decreased without visual loss. Two years later, transient visual obscurations in the right eye recurred with increased frequency. Examination again revealed visual acuities of 20/20, with normal pupillary reactions, mild optic disc edema right eye, and otherwise normal findings. Automated perimetry demonstrated mild blind spot enlargement. MRI showed no significant change in the lesion. The patient preferred to defer treatment, with continuing mild transient visual obscurations in the right eye but no persistent visual loss or other symptoms. Two years later, she again reported increasing visual symptoms and was re-evaluated. Visual acuities remained 20/20 with normal color vision, pupillary reactions, and mildly increased optic disc edema (Fig. 1). MRI, however, remained unchanged, with evidence of perioptic SAS distention and increased CSF collection anterior to the lesion. McNab and Wright (1) described cystic enlargement of the optic nerve sheath in 3 cases of intraorbital meningioma. In one of the cases, optic disc edema was present; at exploratory surgery, the dilated perineural optic nerve space was incised, with emergence of a gush of fluid suggesting high pressure within the perioptic SAS. Lindblom et al. (2) reported 7 cases of focally dilated perioptic SAS anterior to optic nerve sheath meningiomas; 3 of the 7 had chronic optic disc edema, although no other details of the clinical examination were described. Imaging in the 3 cases shown demonstrated posterior orbital tumors with varying anterior extent, all with the sharp demarcation of the tumor from anterior dilated perioptic SAS, as seen in our case. The anterior border of the tumors ranged from 6 to 10 mm posterior to the globe. Killer et al. (4) also described unilateral disc edema secondary to an orbital apex meningioma, anterior to which the perioptic SAS was distended. The mechanism by which the perioptic SAS becomes dilated and its relation to optic disc edema remains unclear. Killer et al. (3) postulated that even in the absence of mechanical tumor blockage of flow around the optic nerve, the perioptic SAS is trabeculated and may be compartmentalized and separate from the remainder of the space in the central nervous system. Decrease of the venous and lymphatic outflow may result in increased pressure and possibly collection of toxins, both contributing to optic disc edema in the absence of elevated intracranial pressure elsewhere. Mader et al. (4) have recently reported on unilateral and asymmetric optic disc edema developing in space travel, again raising the issue of compartmentalization within the perioptic SAS, impaired venous and lymphatic (glymphatic) outflow, at least partially the result of the low-gravity environment. Our case suggests that chronic unilateral optic disc edema may result from dilation of the perioptic SAS anterior to a posterior optic nerve sheath meningioma that does not directly compress the central retinal vein as it traverses the space. Whether the optic disc edema results from locally increased SAS pressure, collection of toxins, or both, remains unproven. Although dilation of the perioptic SAS (with increased T2 weighted MRI CSF signal) is a typical radiographic feature of increased intracranial pressure, any compressive lesion in the orbit may reduce CSF egress from the perioptic SAS and produce dilation. The dilated SAS, especially if unilateral, should prompt detailed orbital imaging with gadolinium administration and fat suppression to detect an occult compressive lesion.

Primary arterial ligation in resection of cancer of the colon: Rational and technic

0179 Recent work by Tschakovsky & Hughson (Am J Physiol Heart Circ Physiol 279: H1007, 2000) indicates that venous emptying serves as a stimulus for vasodilation. This suggests the importance of recognizing the potential Influence of venous function on reactive hyperemic blood flow (RHBF) following occlusion. PURPOSE: To examine the Influence of venous emptying on RHBF. METHODS: Participants underwent an upright incremental cycle ergometer exercise test with gas exchange analysis. Non-dominant forearm in-flow, venous capacitance and outflow were examined in 22 individuals [age = 22±2.34y]. Forearm arterial inflow, venous capacitance, and outflow were obtained two times using strain gauge plethysmography. Forearm blood in flow was estimated at rest and following 5 min of upper arm occlusion. Forearm venous capacitance and outflow were obtained following 5 min of upper arm venous occlusion pressure at 7 mmHg below diastolic blood pressure. Prior to the second measure the arm was passively elevated for 2 minutes. Immediately before returning the arm to its original position the upper arm cuff was again inflated to 240mmHg. Subsequently, RHBF and venous measures were obtained. RESULTS: Average resting in-flow was 2.76±1.15 ml/100ml/min. RHBF was significantly greater following venous emptying (Before: 18.01±4.03; After: 23.6±6.06 ml/100ml/min, p = 0.001). Venous capacitance was also greater (Before: 2.04±0.81; After: 2.90±0.81%, p = 0.001), whereas venous outflow (Before: 36.61±10.86; After: 37.83±12.44 ml/100ml/min, p = 0.18) remained unaffected after venous emptying. Interestingly, venous outflow after emptying was significantly associated with VO2peak (r = 0.78, p = 0.01) as measured on a cycle ergometer. Finally, venous outflow was strongly related to RHBF (r = 0.71, p = 0.01). CONCLUSION: Venous emptying prior to upper arm occlusion results in a significant greater RHBF response and venous capacitance. Moreover, venous outflow was strongly associated with the RHBF response. This suggests the importance of recognizing the Influence of venous outflow on blood inflow. Finally, the strong association between venous outflow and exercise performance warrants further attention.

In Western Europe, gunshot wounds are relatively rare. Nevertheless, the incidence of firearms-related injuries has been increasing in this region over the past two decades. The majority are low-velocity gunshot wounds, in which the severity of injuries is mainly determined by the structures that are damaged in the bullets’ pathway [1]. To our knowledge, there is a very limited number of recent publications on gunshot wounds located solely around the proximal femur [2]. Most publications are either from several decades ago or describe hip region gunshot wounds with concomitant abdominal injuries or bullets’ pathways actually through the hip joint surface [3–10]. Additionally, we found no publications with an overview of diagnostics and treatment of gunshot wounds in the hip region. Nevertheless, these gunshot wounds do require thorough diagnostics and adequate treatment in order to prevent articular and systemic pathologies. We present a case of a low-velocity gunshot wound in the groin with a very particular bullets’ pathway. Advices for diagnostics and treatment of gunshot wounds around the hip are depicted in a concise review of literature. Case

To establish the physiological basis for vascular surgery involving arterio-venous anastomosis in diabetic patients, the question of oxygen supply and lymphatic outflow has been considered in rat skeletal muscles. The dense venular network in the skeletal muscle means that each tissue domain area is small enough to allow adequate oxygenation, consistent with the successful vascular surgery in patients. While sufficient oxygenated blood can reach the resting skeletal muscle through the bypass, there is concern that the resulting high venous pressure might produce a marked increase in lymphatic outflow and destroy the veins and lymphatic system. Consideration of filterability and total surface area of the venular tube now suggests the increase in lymphatic outflow would be only slight. Consideration of filterability and total surface area suggests the increase in lymphatic outflow would be tolerable for the lymphatic system in the hind limb.

Aging is a multifactorial biological process characterized by a progressive decline in functional capacity at the molecular, cellular, tissue, and organismal levels. The aim of this review is to summarize current concepts of aging mechanisms and the prevention of age-related pathologies from a lymphological perspective, taking into account contemporary literature data and the results of our own studies. Currently, two major concepts dominate in gerontology: programmed aging, which considers aging as a genetically determined process, and damage accumulation theories, which associate aging with the progressive accumulation of molecular and cellular damage. The hallmarks of aging include genomic instability, telomere shortening, epigenetic alterations, impaired proteostasis and macroautophagy, dysregulation of nutrient sensing, mitochondrial dysfunction, cellular senescence, stem cell exhaustion, altered intercellular communication, chronic inflammation, dysbiosis, hormonal imbalance, and disturbances in interstitial humoral transport and lymphatic outflow. At the tissue and organ levels, impairment of lymphatic drainage is of particular importance, leading to interstitial fluid stagnation and the accumulation of toxic metabolites, which exacerbate cellular and subcellular dysfunction. Phytotherapeutic agents containing flavonoids, phenolic compounds, terpenoids, glycosides, polysaccharides, and other biologically active substances exhibit antioxidant, anti-inflammatory, and cytoprotective properties. They inhibit lipid peroxidation, reduce excessive nitric oxide production, and contribute to the restoration of interstitial humoral transport and lymphatic outflow. Interstitial humoral transport and the lymphatic system, together with renal mechanisms, play key roles in maintaining body fluid homeostasis. Targeted regulation of lymphatic system function may help reduce tissue congestion, maintain physiological homeostasis, and improve quality of life in the elderly.

Introduction. An important component of the treatment of gunshot wounds is antibiotic therapy. Unfortunately, due to the antibiotic resistance of many strains of microorganisms, there remains a risk of purulent- infectious complications even with prolonged antibiotic therapy. In recent years, methods of physical action, in particular, photodynamic therapy (PDT), have been used to accelerate bacterial decontamination of wounds. Gunshot wounds have their own characteristics that create certain difficulties for the application of the method of photodynamic therapy. Purpose. Аnalyzes the results of the application of the developed PDT method in the complex treatment of gunshot wounds of soft tissues. Materials and methods. A comparison was made of the main indicators of the wound healing process between the wounded of the main group who used PDT (n = 52) and the comparison group (n = 32) who used treatment with complex water-soluble ointments. To increase the effectiveness of the method, the «Photolon» photosensitizer was administered in two ways: by injection infiltration of tissues around the wound and by application directly to the wound surface. The wavelength of laser radiation is 660 nm. The dose of laser energy was 20 J/cm2. Results. The results of the study showed an improvement in the course of the wound process in all respects when using PDT: the period of regression of local edema in the main group on (3.7 ± 0.4) days in the comparison group (6.2 ± 0.5), the period of wound cleansing (4.7 ± 0.6) days (7.3 ± 0.8) days, respectively; the timing of the start of granulation (4.6 ± 0.5) days and (7.8 ± 0.6). At the beginning of treatment, 45 pathogenic strains were isolated in 38 (73.1 %) wounded main groups and 26 strains in 22 (68.7 %) wounded comparison groups. A day after the use of PDT, pathogenic wound microflora was isolated in 5 (9.6 %) wounded main groups — 5 strains and 23 strains in 19 (59.4 %) wounded comparison groups. Conclusions. The effects of PDT were observed: rapid inactivation of pathogenic wound microflora, reduction of edema, pain syndrome and stimulation of granulation growth, which contributes to early closure of wounds.

Managing the trauma pandemic: learning from the past

Inflow Stenoses in Dysfunctional Hemodialysis Access Fistulae and Grafts

Recent literature on the treatment of gunshot wound (GSW) injuries is based on civilian studies from large urban areas in the United States. These studies have challenged the need to hospitalize patients suffering from minor GSW injuries. Instead, these patients are treated in an outpatient setting. The feasibility of extrapolating similar therapeutic intervention in the military is discussed. Combatants experiencing a single, minor GSW injury may require only oral antibiotic treatment on an outpatient basis. In an operational setting, this type of therapeutic intervention would preclude a costly course of intravenous antibiotic therapy with hospitalization and, more importantly, expedite the return of the combatant to his/her command.

Lymphatic regeneration following unilateral hindlimb autotransplantation was studied in 14 Lewis rats using Technetium-99 radiolabeled sulfur colloid (TC-99) lymphoscintigraphy and compared to the lymphatic pattern exhibited in four unoperated control rats. Control animals demonstrate a reproducible flow of lymph along the deep lymphatic system from the foot, draining into the ipsilateral inguinal nodes, and then up to the para-aortic nodes. Following replantation, lymphatic outflow from the replanted limb begins to occur within 3 to 6 days, reaching normal lymphatic clearance within 12 days. However, the pattern of lymphatic flow is ill-defined, relying on multiple small channels of the superficial lymphatic system. In contrast to controls, at 3 hr post TC-99 injection, lymphatic drainage in replanted rats is via the inguinal and axillary nodal regions bilaterally. This abnormal pattern persisted in the replanted animals for the duration of this study, 160 days. It is evident that lymphatic regeneration in this animal model is associated with a rapid return to normal levels of lymphatic clearance via collateral channels within the subcutaneous tissue. The rapidity with which lymphatic drainage is restored, and its localization within the subcutaneous tissue, can explain why replanted tissues and microvascular free flaps seldom develop lymphedema. In addition, the rat hindlimb replantation model may prove useful for studies of the general mechanisms and specific factors responsible for lymphangiogenesis.

Objective. To summarize the available data on the role of lymphatic insufficiency in CVI and its correction using CVD treatment approaches. Material and methods. We reviewed the PubMed and eLibrary databases using the keywords «phlebolymphedema», as well as analyzed available articles. Results. Revising the Starling’s law excluding fluid reabsorption at the venous end of the capillary and placing responsibility for fluid drainage on lymphatic system is important for the concept of phlebolymphedema. Progressive venous hypertension and increased plasma filtration can lead to functional insufficiency and damage to lymphatic system. Available data confirm progressive impairment of lymphatic outflow in parallel with progression of CVD. Modern methods of morphofunctional assessment of superficial lymphatic system, in particular ICG lymphography, allows us to take a new look at pathogenesis of CVI. Standard methods of CVD treatment can have a positive effect on lymphatic outflow, but available data are contradictory. Therapeutic effect of compression therapy is mainly limited to fluid movement through the interstitium towards intact lymphatic vessels. Various drugs including micronized purified flavonoid fraction demonstrate a positive effect on lymphatic drainage. Appropriate therapy is followed by effective relief of venospecific subjective symptoms, chronic edema and trophic disorders. Surgery for superficial and deep veins can improve lymphatic drainage, but clinical results are naturally worse in case of lymphatic insufficiency. Conclusion. Damage to lymphatic system is essential for progressive forms of CVD that emphasizes the need for further study of this issue and development of prevention methods.

The cerebrovascular bed and cerebrospinal fluid circulation have been modeled extensively except for the cerebral venous outflow, which is the object of this study. A hydraulic experiment was designed for perfusion of a collapsible tube in a pressurized chamber to simulate the venous outflow from the cranial cavity. The laboratory measurements demonstrate that the majority of change in venous flow can be attributed to either inflow pressure when the outflow is open, or the upstream transmural pressure when outflow is collapsed. On this basis, we propose a mathematical model for pressure distribution along the venous outflow pathway depending on cerebral blood flow and intracranial pressure. The model explains the physiological strong coupling between intracranial pressure and venous pressure in the bridging veins, and we discuss the limits of applicability of the Starling resistor formula to the venous flow rates. The model provides a complementary explanation for ventricular collapse and origin of subdural hematomas resulting from overshunting in hydrocephalus. The noncontinuous pressure flow characteristic of the venous outflow is pinpointed as a possible source of the spontaneous generation of intracranial slow waves. A new conceptual mathematical model can be used to explain the relationship between pressures and flow at the venous outflow from the cranium.

Rationale. The treatment of patients with gunshot wounds of soft tissues is a complex task for the entire healthcare system. Despite the achievements of modern medicine, the problem of purulent – septic complications of gunshot injury remains one of the most urgent. The development and application of new methods of gunshot wound treatment makes it possible to improve the results of specialized medical care for victims. Objective : To evaluate the effectiveness and safety of using a medical device – carbon atraumatic wipes “InKar” and epidermal growth factor with silver sulfadiazine in the complex treatment of soft tissue gunshot wounds complicated by a purulent-necrotic process. Materials and methods . A retrospective, randomized, single-center, clinical trial was conducted on two parallel groups of patients. The study involved 86 wounded with gunshot wounds to the soft tissues of the trunk and limbs, brought from the area of the SMO. The main group included 46 patients who, in the complex local treatment of gunshot wounds, used carbon absorbent and therapeutic wipes “InKar” (in phase I) with the treatment of wound surfaces with “Ebermin” ointment during bandages. The control group included 40 patients who received standard treatment. The criteria for assessing the dynamics of the wound process were: cytological and bacteriological studies of wound exudate, visual and photographic assessment of the appearance of granulation tissue in the wound, and the timing of its purification. The dynamics of the systemic inflammatory response syndrome was based on clinical and laboratory data, and quality of life was assessed using the SF 36 questionnaire. Results. The use of carbon and therapeutic bandages for the local treatment of gunshot wounds in symbiosis with epidermal growth factor and silver sulfadiazine in the main group provided (twice) faster wound healing, the absence of complications (progression of the purulent -necrotic process, secondary infection) and a significant reduction in systemic inflammatory response syndrome and treatment time, according to compared with patients in the control group. An assessment of the quality of life of the wounded in both groups confirmed a faster recovery of functional, physical, and psycho-emotional parameters in the patients of the main cohort. Conclusion : effective and safe treatment of gunshot wounds is possible with the rational and competent (depending on the phase of the wound process) use of modern wound coverings. At the same time, new prospects are opening up for the use of epidermal growth factors in broad clinical practice, which provide a reliable regenerative component in the healing of gunshot wounds complicated by purulent infection of various localization.

Objective. To present the lymphological approaches to diagnosis and treatment of acute and chronic venous diseases. Material and methods. There were 692 patients with venous diseases of the lower extremities (thrombophlebitis of superficial veins — 153, deep vein thrombosis — 154, chronic venous disease — 385). To clarify the state of lymphatic system, we used contrast-enhanced lymphography in 22 patients, radioisotope lymphoscintigraphy in 75 patients and ultrasound in 325 patients. These results were compared with data in 34 people without vascular abnormalities. Correction of lymphatic outflow disorders implied regional stimulation of lymphatic drainage. Lymphotropic therapy included subcutaneous administration of agents enhancing lymphatic resorption and lymphatic drainage. We also performed lymphatic drainage procedures simultaneously with surgical interventions on venous system. Patients with edema following post-thrombotic disease underwent fenestration of the fascia of the leg, tunnelization of subcutaneous fat base, external drainage of lymphocele, liposuction and, if indicated, imposing lymphovenous anastomoses. We compared healing of ulcers associated with post-thrombotic disease in the main group with lymphological approaches (35 patients) and the control group with standard techniques (27 patients). Results. Lymphoscintigraphy data revealed that initial stages of venous thrombosis were accompanied by 1.2—1.4-fold lymph flow acceleration in thrombosis of deep and superficial veins and radiopharmaceutical excretion increase from 29 to 42% compared to healthy individuals. In 14 days after venous thrombosis, lymph flow and resorption of radiopharmaceuticals decreased by approximately 2 times. Venous insufficiency was followed by slowdown in lymphatic drainage. Surgical and conservative lymphological approaches in patients with lymphatic and venous insufficiency increased lymphatic drainage and improved microcirculation. When comparing with the control group, we found more intense debridement, granulation and epithelization of trophic ulcers (p<0.001). Conclusion. Venous diseases lead to significant disturbances in lymphatic drainage. Lymphological approaches are perspective in the treatment of patients with severe trophic disorders.