Anterior Tibial Artery Research Articles

Differential regional perfusion of the human anterior cruciate ligament: quantitative magnetic resonance imaging assessment

PurposeSurgical reconstruction is the current standard for ACL rupture treatment in active individuals. Recently, there is renewed interest in primary repair of proximal ACL tears. Despite this, ACL biology and healing potential are currently not well understood. Vascularity is paramount in ACL healing; however, previous ACL vascularity studies have been limited to qualitative histological and dissection-based techniques. The study objective was to use contrast-enhanced quantitative-MRI to compare relative perfusion of proximal, middle, and distal thirds of the in situ ACL. We hypothesized perfusion would be greatest in the proximal third.MethodsFourteen cadaveric knees were studied (8 females, 6 males), age 25–61 years. Superficial femoral, anterior tibial, and posterior tibial arteries were cannulated; without intraarticular dissection. Contrast-enhanced quantitative-MRI was performed using a previously established protocol. ACL regions corresponding to proximal, middle, and distal thirds were identified on sagittal-oblique pre-contrast images. Signal enhancement (normalized to tibial plateau cartilage) was quantified to represent regional perfusion as a percentage of total ACL perfusion. Comparative statistics were computed using repeated measures ANOVA, and pairwise comparisons performed using the Bonferroni method.ResultsRelative perfusion to proximal, middle, and distal ACL zones were 56.0% ±17.4%, 28.2% ±14.6%, and 15.8% ±16.3%, respectively (p = 0.002). Relative perfusion to the proximal third was significantly greater than middle (p = 0.007) and distal (p = 0.001). No statistically relevant difference in relative perfusion was found to middle and distal thirds (p = 0.281). Post-hoc subgroup analysis demonstrated greater proximal perfusion in males (66.9% ± 17.3%) than females (47.8% ± 13.0%), p = 0.036.ConclusionUsing quantitative-MRI, in situ adult ACL demonstrated greatest relative perfusion to the proximal third, nearly 2 times greater than the middle third and 3 times greater than the distal third. Knowledge of differential ACL vascular supply is important for understanding pathogenesis of ACL injury and the process of biological healing following various forms of surgical treatment.

Patterns of Infra-Popliteal Arterial Disease

Introduction The growth of the diabetic population and the increased prevalence of peripheral arterial disease (PAD) below the knee has created an increased demand for duplex ultrasound (DUS) evaluation of the infra-popliteal arteries. The purpose of this study is to show how DUS can be used to identify the patterns of infra-popliteal arterial occlusive disease. Methods: We performed infra-popliteal duplex ultrasound scans on 100 consecutive patients (199 limbs) with suspected PAD. Peak systolic velocity (PSV) was obtained from the anterior tibial artery (ATA) and posterior tibial artery (PTA) at the distal, mid, and proximal calf levels. The acceleration time (AT) was measured in the distal ATA and PTA segments. Results: The PTA was the infra-popliteal artery that was most often totally occluded (21% of limbs). Segmental PTA occlusions occurred predominantly in the proximal and distal segments. The ATA was totally occluded in 8% of limbs, with segmental occlusions located predominantly in the mid segment. We also confirmed that proximal PAD prolongs distal infra-popliteal artery AT and reduces distal PSV. Conclusion: These data add to our understanding of the patterns of infra-popliteal arterial disease and should be of interest to sonographers who perform DUS of the lower extremity arteries.

Successful Systemic Heparinization for Treatment of Acute Arterial Occlusion of Tibial Artery and Aortic Mural Thrombi in a Patient With COVID-19 Infection: A Case Report

The present case report described a 60-year-old woman who developed multiple isolated acute arterial occlusions of the left anterior tibial artery, peroneal artery, and posterior tibial artery with aortic mural thrombi in the infrarenal aorta during treatment of COVID-19 pneumonia. The patient underwent conservative treatment by systemic heparinization and switched to low molecular weight heparin. She experienced clinical improvement within hours of medical treatment and complete resolution of the tibial artery thrombosis after two weeks of treatment. The aortic mural thrombi was evaluated by computed tomography angiography (CTA) abdomen and lower extremities and resolved after six weeks of anticoagulant administration. Keywords: Acute limb ischemia; Aortic mural thrombi; Thrombosis; COVID-19

The arteries of the musculoskeletal system of siamangs, and a comparison with other hylobatids, greater apes, and humans.

Limited research on the gross anatomy of the blood vessels has been conducted on hylobatids, or lesser apes, so far. Here, we present a detailed study of the arteries of siamangs (Symphalangus) and compare our findings with data compiled from our previous studies as well as from the literature about other hylobatids, greater apes, and humans. In particular, a three-dimensionalfull-body computed tomography data set of a siamang neonate was analyzed in detail for this study, with notable findings in the head and neck, thorax, upper limb, abdomen and pelvis, and lower limb. Of the 62 arteries that we studied in detail, a total of 20 arteries that have never been described in detail in hylobatids are reported in this study. Key similarities to other apes differing from humans include the existence of a humeral common circumflex trunk and the origination of the dorsalis pedis from the posterior tibial artery or saphenous artery instead of the anterior tibial artery. Similarities to humans differing from other apes include the separation of the lingual and facial arteries and the origination of the profunda brachii from the brachial artery instead of the axillary artery. Our research and broader comparisons, therefore, contribute to knowledge about the soft tissues of hylobatids, other apes, and primates in general and facilitate a better understanding of the anatomical evolution and key differences and similarities among these taxa.

Surgical Deep Vein Arterialization: Adding to the Armamentarium of Complex Limb Salvage

Patients with severe peripheral arterial disease with limited or nonexistent arterial runoff, the so-called "desert foot", challenge efforts at limb preservation. Deep vein arterialization (DVA) involves incorporating a venous target as an outflow to achieve revascularization in these complex patients. We report outcomes in an initial series of patients undergoing DVA as a component of surgical bypass. Over a 2-year period, 10 patients underwent bypass incorporating DVA due to severely disadvantaged runoff using a heparin-bonded expanded polytetrafluoroethylene conduit. Indications for surgery included tissue loss (8) or ischemic rest pain (2) in patients who had failed endovascular (3) or surgical (7) revascularization. Inflow arteries for bypass ranged from external iliac to below knee popliteal. Outflow anastomoses incorporated a common ostium arteriovenous fistula between anterior tibial (5), posterior tibial (2), peroneal (1) or plantaris pedis (2) arteries, and corresponding tibial veins. Prior to anastomotic completion, tibial vein valves were lysed to allow venous arterialization by a way of retrograde flow. Postoperative medical regimen included dual antiplatelet (2), antiplatelet plus anticoagulation (7), or anticoagulation alone (1). Primary patency was maintained in 7 of 10 grafts (average: 4.1 months, range: 1-18 months). Limb salvage was achieved in 8 of 10 patients (average: 6 months, range: 1-18 months). Two below knee amputations were performed after graft occlusion due to extensive tissue loss and infection, whereas 1 patient maintained limb salvage despite graft occlusion after successful wound healing. This initial experience describes surgical DVA using a prosthetic conduit in conjunction with an arteriovenous fistula at the distal anastomosis in patients with threatened limb loss and severely disadvantaged tibial runoff. Although evidence for long-term efficacy is uncertain, preliminary outcomes warrant further investigation as this technique may allow for surgical revascularization resulting in limb preservation for patients with no other alternative than amputation.

Proximal Branching of the Anterior Tibial Artery From the Popliteal Artery Increases the Risk of Vascular Injury During Total Knee Arthroplasty: A Retrospective Analysis Using Preoperative Magnetic Resonance Imaging and Intraoperative Findings.

IntroductionArterial injury following total knee arthroplasty (TKA) can be life-threatening. There are some anatomical variations in the popliteal artery (PA) and its branches. In most cases, the PA branches into the anterior tibial artery (ATA) and posterior tibial artery (PTA), which are usually distal to the height of tibial resection in TKA. However, some cases show that the PA branches into the ATA and PTA proximal to the height of tibial resection in TKA. This study aimed to assess the distance from the posterior cortex of the proximal tibia to the anterior wall of the PA or ATA at the height of the tibial cut line, during TKA in the distal and proximal branch groups.Methods129 patients (6 patients in the proximal branch group and 123 patients in the distal branch group) were enrolled for this study. For prediction of the distance from the posterior cortex of the proximal tibia to the anterior wall of the PA or ATA, preoperative sagittal and coronal magnetic resonance images and postoperative radiographs were evaluated.ResultsThe distance between the posterior cortex of the proximal tibia and the anterior wall of the PA or ATA at the height of the tibial cut line was 1.8 ± 1.1 mm in the proximal branch group and 6.1 ± 2.6 mm in the distal branch group, which was significantly closer in the proximal group (P < .05).DiscussionThe rate of proximal branching was 4.7%. This study clarified that the proximal branching of the ATA from PA significantly decreased the distance between the posterior cortex of the proximal tibia and the anterior wall of the artery.ConclusionsThe proximal branch group has a high risk for arterial injury as the artery may be close to the saw, and appropriate retraction should be performed.

Nerve branches to the anterior tibial artery: Clinical application

Arteries receive vascular branches (VBs) from peripheral nerves. VBs are thought to be involved in arterial constriction. Although the anterior tibial artery (ATA) receives VBs, information on their branching patterns and distribution areas remains limited. The aim of this study was to investigate the anatomical structures of the VBs reaching the ATA. Forty cadaver limbs were examined to assess the branching patterns and distribution areas of the VBs reaching the ATA. The VBs reaching the ATA ramified from the deep fibular nerve (DFN), and the ATA received two or three VBs in each limb. The following mean distances from the head of fibula to the points at which the VBs reached the ATA were measured: all the VBs, 1st VB, 2nd VB and 3rd VB. The measurements were 51.5 ± 23.2 mm, 33.3 ± 3.7 mm, 53.3 ± 18.6 mm, and 72.2 ± 24.5 mm, respectively. In all limbs, the DFN and the ATA converged after the DFN branched into the 1st VB. The 2nd VB in 38 of 40 limbs and the 3rd VB in 20 of 32 limbs were distributed in the ATA proximal to the convergence point of the ATA and the DFN. These findings revealed that all VBs reaching the ATA ramified from the DFN in all limbs. The ATA received two or three VBs, and all the 1st VBs distributed to the ATA proximal to the convergence point.

Regional haemodynamic variables and perfusion index in the evaluation of sciatic nerve block: a prospective observational trial

ObjectiveWe determined whether regional haemodynamics and perfusion index (PI) could be reliable indicators of a successful sciatic nerve block (SNB).DesignProspective observational trial.SettingA tertiary teaching hospital in China from April 2020...

Popliteal artery branching variations on computed tomography angiography of 1542 lower limbs and its associated factors.

The identification of popliteal artery branching variation is of anatomical importance for surgical and endovascular procedures in the posterior region of the knee and below. To evaluate the variations and associated factors of popliteal artery branching by computed tomography angiography (CTA). CTA of the lower extremities of 1542 lower limbs in 771 patients (513 men and 258 women) were retrospectively reviewed to assess the popliteal artery branching patterns. The patient's sex, side of lower limbs, and population were recorded and evaluated for their association with popliteal artery branching patterns. P < 0.05 was considered to indicate statistical significance. Variations in the branching of the popliteal artery were recorded in 9.3% of patients. The three most common variations were found to be hypoplastic-aplastic posterior tibial artery (PT) (3.6%), trifurcation (2.0%), and hypoplastic-aplastic anterior tibial artery (0.8%). A new pattern was detected in 2 (0.1%) cases, which were described as double PTs. Statistically significant differences were noted in the proportion of variation branching between the male and female groups (odds ratio = 1.52; 95% confidence interval = 1.07-2.16; P = 0.02). The findings on popliteal variational branching patterns in the present study were in conformance to previous reports. Our study identified a novel variation of popliteal artery branching, which has not been mentioned in the literature so far. Sex was found to be an associated factor of branching variation.

The Patency of Tibial/Peroneal Arteries Affects the Increment of Regional Tissue Saturation of Oxygen in Each Angiosome after Superficial Femoral Artery Revascularization.

Objective: The angiosome model is a controversial concept in the revascularization of patients with chronic limb-threatening ischemia (CLTI). The aim of this study was to demonstrate the importance of patency of the tibial/peroneal arteries for regional tissue oxygenation in each angiosome during endovascular therapy (EVT) of the superficial femoral artery (SFA).Materials and Methods: We devised a novel near-infrared spectroscopy oximeter, “TOE-20,” for real-time monitoring of regional tissue oxygen saturation (rSO2). Using TOE-20, we prospectively assessed rSO2 at each angiosome in 23 CLTI patients who underwent successful revascularization of the SFA. During EVT, three sensor probes were placed at the dorsal foot, plantar foot, and outer ankle for rSO2 monitoring.Results: At the end of EVT, rSO2 at all angiosomes was significantly elevated by SFA revascularization. The change in rSO2 in each angiosome was larger in patients with patent relevant arteries than in those with occluded relevant arteries (i.e., anterior tibial artery patency, posterior tibial artery patency, and peroneal artery patency).Conclusion: The patency of the tibial/peroneal arteries is important for regional tissue oxygenation in EVT. Using TOE-20 and rSO2-based revascularization, it may possible to anticipate whether an ischemic ulcer will heal or not.

Below-the-Ankle Orbital Atherectomy in Chronic Limb-Threatening Ischemia Patients as a Bailout Strategy for Limb Salvage: Early Clinical Experience

PurposeTo evaluate the feasibility and early outcomes of below the ankle orbital atherectomy in chronic limb-threatening ischemia in patients with calcified foot arteries. Methods12 patients (mean age 69.4 ± 14.7; range 57 to 85 years) who were affected by diabetes underwent orbital atherectomy below the knee and ankle arterial segments. Technical success was defined as orbital atherectomy passage and debulked the calcified lesion, delivery of adjunctive therapy, and < 30% residual stenosis at final angiogram. The procedural outcome included complications, amputation-free survival, and freedom from clinically-driven target lesion revascularization at 30-days and 6-months of follow-up. ResultsOrbital atherectomy was performed in 3 cases in Anterior tibial (AT) and dorsalis pedis (Ped) arteries + Posterior tibial (PT) and Lateral Plantar (Lat Plan), 5 cases in PT and Lat Plan arteries, 1 case of PT and Medial Plantar, 1 case of Peroneal and Plan Lat, and 2 cases of AT and Ped. After atherectomy, we used a drug-coated balloon (DCB) angioplasty.Technical success was achieved in 11 (91.6%) cases. No deaths were registered during the follow-up. The limb salvage rate was 100%, and no major amputations were registered. Amputation-free survival was 50%. Freedom from CD-TLR was 100% at 30 days and 91.7% at 6-months. One patient underwent a TLR at three months. No major cardiovascular events, limb events, or significant procedure-related complications were registered. ConclusionsCSI orbital atherectomy and DCB angioplasty appear a feasible and promissor treatment options in diabetic CLTI patients.

Association Between Lower Extremity Arterial Disease and Various Sitting Positions.

BackgroundLower extremity arterial disease is usually a widespread vessel disease of atherosclerotic origin with a predisposition for certain anatomical sites. This study aimed to evaluate the relationship between lower extremity arterial disease anatomic and clinical features and various sitting patterns. MethodsPatients who underwent invasive peripheral angiography and who were diagnosed with lower extremity arterial disease in a single tertiary center were included in the study. Six sitting positions were defined. Sitting patterns and other clinical data were collected using a standardized questionnaire. ResultsIn this study, 150 patients diagnosed with lower extremity arterial disease who underwent invasive peripheral angiography were enrolled. The mean age of the study population was 66.2 ± 9.5 years, and an overwhelming majority of the participants were men (91.3% vs. 8.7%). A significant relationship was found between sitting positions #1-5 and right-sided lesions, as well as sitting positions #1-4 and left-sided lesions (sitting position #5 and right-sided lesions P = .039, all others P < .001). Longer and more frequent sitting conditions were found to be associated with lesions in the proximal arteries (common iliac artery and external iliac artery) but not in the more distal artery (superficial femoral artery, popliteal artery, anterior tibial artery, and posterior tibial artery) lesions. ConclusionsA clear relationship between sitting positions and lower extremity arterial disease sites was demonstrated. This data indicate that sitting patterns should be evaluated in every lower extremity arterial disease patient.

Abnormal Lower Extremity Hemodynamics at Doppler US in Children with Sickle Cell Anemia.

Background Children with sickle cell anemia (SCA) are predisposed to developing leg ulcers in early adolescence; however, the underlying physiologic mechanisms are not well understood, which hinders the development of prophylactic antiulcer interventions. Purpose To determine if occlusive arterial disease or abnormal hemodynamics exist in the lower limb peripheral arteries of children with SCA. Materials and Methods This was a prospective cross-sectional study conducted between July 2020 and May 2021. Two groups of participants were enrolled: children with SCA and healthy controls. Each child had their anthropometric measurements taken, followed by B-mode, color Doppler, and spectral Doppler US evaluation of the distal anterior and posterior tibial arteries. Ankle-brachial index evaluation was also performed. Hemodynamic values were compared between children with SCA and healthy controls, with statistical significance set at the P < .05 level. Results Forty-five children with SCA (mean age, 9.5 years ± 3.7 [SD]; 26 boys) and 45 healthy controls (mean age, 9.3 years ± 3.8; 25 boys) were evaluated. Children with SCA had higher peak systolic velocities, end-diastolic velocities, and blood volume flow in their distal anterior and posterior tibial arteries compared with the healthy participants (P < .001 across all 12 measurements). Children with SCA also had lower resistive index and pulsatility index values compared with healthy controls in at least one of the anterior and posterior tibial arteries bilaterally. Monophasic spectral patterns were exclusively observed in participants with SCA. The ankle-brachial index values for the participants with SCA (mean, 1.09 ± 0.08) and healthy participants (mean, 1.06 ± 0.02) were within normal range. Conclusion Abnormal peripheral hemodynamic characteristics were found in the lower limbs of children with sickle cell anemia. No evidence of occlusive peripheral artery disease was present. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Paltiel in this issue.

A Lucky Case of Successful Free Fibula Osteocutaneous Flap Harvest in Peronea Arteria Magna.

The free fibula flap (FFF) is based on the peroneal artery (PA) system, and it is well known that several anatomical variations of the lower limb vascular system exist, including peronea arteria magna (PAM). PAM is a rare congenital variation in which both anterior tibial artery and posterior tibial artery are either aplastic or hypoplastic, and as a result, PA will be the dominant blood supply to the foot. This variation was described as type III-C in Kim-Lippert's Classification of the Infra-Popliteal Arterial Branching Variations. The awareness of its existence is crucial as it often precludes FFF from being harvested due to the risk of significant limb ischemia and limb loss. Despite some literature reporting donor site complications and impending limb loss following FFF harvest in PAM, preoperative vascular mapping before FFF transfer remains controversial among the microsurgeons. We present a case with an incidental intraoperative finding of PAM that had a successful FFF harvest by luck, without preoperative vascular mapping.

Abstract 051: Association Between Body Mass Index Trajectories From Early To Middle Childhood And Biomarkers Of Cardiometabolic Risk Among Children Living In Low-income And Racially/ethnically Diverse Households

Introduction: Substantial cross-sectional evidence exists supporting an association between high body mass index (BMI) during childhood and increased cardiometabolic risk factors. However, less is known about longitudinal associations of child BMI trajectories with biomarkers of cardiometabolic risk. The objective of this study was to (1) identify distinct BMI trajectories during childhood from ages 2-11 years and (2) evaluate the association of these BMI trajectories with biomarkers of cardiometabolic risk at ages 7-11 years. Methods: The analytic sample included 338 children living in low-income and racially/ethnically diverse households who participated in the NET-Works randomized intervention trial and the NET-Works 2 prospective follow-up study. BMI was measured at baseline (when children were 2-4 years of age) and again at 1-, 2-, 3- and 5-year follow-up visits. Percent of the 95 th percentile of BMI (%BMIp95) was the BMI metric calculated at each time point. At the 5-year follow-up visit, children (aged 7 to 11 years) completed assessments for carotid to anterior tibial artery pulse wave velocity (PWV), C-reactive protein (CRP), leptin, adiponectin, and oxidized low-density lipoprotein (oxLDL). Group-based trajectory modeling was used to identify child %BMIp95 trajectory groups. Adjusted linear regressions evaluated the associations between %BMIp95 trajectory groups and PWV, CRP, leptin, adiponectin, and oxLDL. Results: We identified two trajectory groups: (1) 75% of children had a moderate-decreasing trajectory (baseline BMI was below the 95th percentile of BMI and followed a moderate-decreasing trajectory over time), and (2) 25% had a marked-increasing trajectory (baseline BMI was above the 95th percentile of BMI and followed a steep increase over time). Relative to children in the moderate-decrease trajectory group, children in the marked-increase trajectory group had higher mean adjusted CRP (3.3 mg/L, 95% CI [1.6, 4.9]) and leptin (62.5 ng/mL, 95% CI [44.0, 80.9]), and lower levels of adiponectin (-1.4 μg/mL, 95% CI [-2.5, -0.1]). Differences in PWV and oxLDL were small and not statistically significant. Conclusions: Two unique BMI trajectories were observed among children living in low-income and racially/ethnically diverse households. Compared to children with steady BMI decrease over time, those with steady BMI increase over time had a higher baseline BMI and adverse inflammatory and adipokine profiles later in childhood. However, we found no evidence of differences in arterial stiffness, which could develop later in adolescence or adulthood. This study provides additional objective evidence supporting the importance of early-life tracking of BMI using the %BMIp95 metric and lifestyle interventions to reduce the risk of obesity and emerging cardiometabolic risk during childhood.

Microsurgical anastomosis using anterior versus posterior tibial artery in lower limb free tissue transfer.

Soft tissue lower limb reconstruction often requires free tissue transfer. We investigated whether the target vessels used for micro-vascular anastomosis in the lower limb influences microsurgical outcomes. Data from Plastic Surgery Departments of a major tertiary hospital in the United Kingdom (Leeds General Infirmary, LGI) and Australia (Princess Alexandra Hospital, PAH) were retrospectively analysed. Patients who underwent lower limb free flap reconstruction using the posterior (PTA) or anterior tibial artery (ATA) were included. Patient demographics, free flap and microvascular anastomosis details were analysed. Primary outcome was flap failure. Secondary outcome was return to theatre. Two hundred and thirty-four free flaps were included (PAH 115; LGI 119). 60% were muscle flaps. Eighty-one percent of patients were male, with trauma the cause in 82%. PTA was used for microsurgical anastomosis in 70% of cases. Venae comitantes were preferred (96%) for venous anastomosis. PTA group showed a higher proportion of patients with trauma as the mechanism of injury. ATA group was more likely to have an end-to-end arterial anastomosis configuration. Total flap loss was 3.8%. There was no clinically significant difference in flap failure or return to theatre using ATA versus PTA. Incidence of lower limb free flap failure is low (<5%) and not influenced by use of ATA versus PTA for microsurgical anastomosis. The choice of target vessels for microsurgical reconstruction of the lower limb should be predicated upon factors other than aversion to one or another vessel. If all other microsurgical considerations are equal, the surgeon can exercise personal preference.

Surgical Deep Vein Arterialization: Adding To The Armamentarium Of Complex Limb Salvage

INTRODUCTION AND OBJECTIVES Patients with severe peripheral arterial disease with limited or non-existent arterial runoff, the so-called “desert foot”, challenge efforts at limb preservation. Deep vein arterialization (DVA) involves incorporating a venous target as outflow to achieve revascularization in these complex patients. We report outcomes in an initial series of patients undergoing DVA as a component of surgical bypass. METHODS Over a 2-year period, 10 patients underwent bypass incorporating DVA due to severely disadvantaged runoff using a heparin-bonded ePTFE conduit. Indications for surgery included tissue loss (8) or ischemic rest pain (2) in patients who had failed prior endovascular (3) or surgical (7) revascularization. Inflow arteries for bypass ranged from external iliac to below knee popliteal. Outflow anastomoses incorporated a common ostium AV fistula between anterior tibial (5), posterior tibial (2), peroneal (1) or plantaris pedis (2) arteries and corresponding tibial veins. Prior to anastomotic completion, tibial vein valves were lysed to allow venous arterialization through retrograde flow. Postoperative medical regimen included dual antiplatelet (2), antiplatelet plus anticoagulation (7), or anticoagulation alone (1). RESULTS Primary patency was maintained in 7 of 10 grafts (average of 4.1 months, range 1-18 months). Limb salvage was achieved in 8 of 10 patients (average of 6 months, range 1-18 months). 2 below knee amputations were performed after graft occlusion due to extensive tissue loss and infection, while 1 patient maintained limb salvage despite graft occlusion after successful wound healing. CONCLUSIONS This initial experience describes surgical DVA using a prosthetic conduit in conjunction with an AV fistula at the distal anastomosis in patients with threatened limb loss and severely disadvantaged tibial runoff. Although evidence for long-term efficacy is uncertain, further investigation is warranted as this technique may allow for surgical bypass resulting in limb preservation for patients with no other alternative than amputation. Patients with severe peripheral arterial disease with limited or non-existent arterial runoff, the so-called “desert foot”, challenge efforts at limb preservation. Deep vein arterialization (DVA) involves incorporating a venous target as outflow to achieve revascularization in these complex patients. We report outcomes in an initial series of patients undergoing DVA as a component of surgical bypass. Over a 2-year period, 10 patients underwent bypass incorporating DVA due to severely disadvantaged runoff using a heparin-bonded ePTFE conduit. Indications for surgery included tissue loss (8) or ischemic rest pain (2) in patients who had failed prior endovascular (3) or surgical (7) revascularization. Inflow arteries for bypass ranged from external iliac to below knee popliteal. Outflow anastomoses incorporated a common ostium AV fistula between anterior tibial (5), posterior tibial (2), peroneal (1) or plantaris pedis (2) arteries and corresponding tibial veins. Prior to anastomotic completion, tibial vein valves were lysed to allow venous arterialization through retrograde flow. Postoperative medical regimen included dual antiplatelet (2), antiplatelet plus anticoagulation (7), or anticoagulation alone (1). Primary patency was maintained in 7 of 10 grafts (average of 4.1 months, range 1-18 months). Limb salvage was achieved in 8 of 10 patients (average of 6 months, range 1-18 months). 2 below knee amputations were performed after graft occlusion due to extensive tissue loss and infection, while 1 patient maintained limb salvage despite graft occlusion after successful wound healing. This initial experience describes surgical DVA using a prosthetic conduit in conjunction with an AV fistula at the distal anastomosis in patients with threatened limb loss and severely disadvantaged tibial runoff. Although evidence for long-term efficacy is uncertain, further investigation is warranted as this technique may allow for surgical bypass resulting in limb preservation for patients with no other alternative than amputation.

Neglected Infected Post-traumatic Pseudoaneurysms of Anterior Tibial Artery: A Case Report and the Lessons Learnt.

Neglected Infected Post-traumatic Pseudoaneurysms of Anterior Tibial Artery: A Case Report and the Lessons Learnt.

Low-vacuum negative pressure wound therapy protocol for complex wounds with exposed vessels.

Treating high-risk surgical patients with complex wounds over exposed blood vessels is a challenge. Guided wound healing may be the only treatment possible. Negative pressure wound therapy (NPWT) is not recommended in these cases. The authors challenged these current recommendations and share their preliminary experience. The authors adapted a NPWT protocol that uses low-vacuum continuous pressure (-80mmHg) with a silicone sheath and gauze/foam dressing between the wound bed and the device. They monitored the clinical features of patients' wounds to detect bleeding/ischaemia early on. Dressings were changed every 72-96 hours. This protocol was followed in five male patients (aged 23-68 years) with complex wounds over exposed vessels. Two cases were foot crush injuries, one midfoot amputation, one hand self-subamputation and one vascular bypass infection. Comorbidities included monoarterial limbs/stump, severe arteriopathy and psychiatric disorder. The exposed vessels were femoral, radial and ulnar, anterior and posterior tibial arteries and veins. Mean treatment lasted 37 days (range 20-61 days). No episodes of severe bleeding/ischaemia of the extremities were observed. Treatment was discontinued once debridement was complete and granulation tissue allowed spontaneous closure/grafting. All wounds appeared stable at 1-year follow-up. The low-vacuum NPWT protocol was successful in solving five difficult cases. This regimen reduces risks associated with NPWT use on wounds with exposed vessels. The authors believe further validation is required to strengthen the evidence. However, preliminary data are encouraging and might help to change future NPWT recommendations by extending the indications for its use to exposed vessels.

A comparative study to assess vascular health in previously diagnosed patients of kawasaki disease

Background: Kawasaki disease, the commonest cause of multisystem vasculitis in children, was believed initially as a one-time disease. Long-term follow-up reveals that endothelial dysfunction persists in post-Kawasaki disease patients with and without coronary lesions and predisposes to atherosclerosis.Aims and Objectives: To establish the endothelial dysfunction and to correlate it with premature atherosclerosis in Kawasaki disease patients.Settings and Design: Prospective comparative study.Materials and Methods: Thirty patients of Kawasaki disease (age, 6 months to 20 years) were compared to the age matched control population and evaluated 2 times (1st F/U and 2nd F/U) at an interval of 6 months. USG Doppler was used to measure intimal thickness of carotid arteries CAD-IT, flow character and Resistive Index of anterior ATA-RI and posterior tibial arteries PTA-RI. Echocardiography was used to detect perivascular hyperintensity, dilatation and aneurysm of coronary arteries. Ongoing inflammation was documented by C- reactive protein (CRP) level. Coronary involvement (dilatation, small, medium, giant CAA) was determined by the z-scores adjusted to patients' body surface area (BSA) (AHA guidelines 2017).Statistical analysis used: Mean, paired t-test, GEE model, Odds ratio.Results: Significantly elevated CRP levels were observed in both the 1st follow up (p=0.0005) and 2nd follow up (p=0.000001) compared to control value. A significant rise (p<0.05) in total cholesterol, triglyceride levels, ATA-RI, PTA-RI and CAD-IT were seen. Seven patients developed coronary aneurysm of which three had persistent lesion.Conclusions: Kawasaki disease is not a one -time disease. Persistent endothelial dysfunction continues. CRP, total cholesterol, triglyceride, and USG doppler of coronary, carotids as well as peripheral arteries were found abnormal in follow up. So, these patients need to be followed up for a long period.