Neonatal near-interrupted aortic arch is a medical emergency that requires immediate attention, with primary surgical repair being the preferred treatment. This report describes a critically ill neonate with a complex, near-interrupted aortic arch in whom surgical repair was not feasible. The patient was successfully stabilized with rescue stent placement via a less commonly used approach-left axillary artery access.

This study evaluated operative mortality and morbidity in acute type A aortic dissection (ATAAD) over 25 years, focusing on the impact of evolving surgical techniques and patient selection. A retrospective analysis was conducted of 498 patients undergoing ATAAD repair between 1998 and 2022 at a tertiary aortic center. Patients were stratified into surgical eras 1 (1998-2010, n = 190) and 2 (2011-2022, n = 308). The primary outcome was operative mortality, and secondary outcomes included major adverse events, stratified by organ system. Patients in era 2 were older (era 1, 58 [SD, 13.7] years vs era 2, 60.4 [SD, 13.4] years; P = .06), had higher rates of preoperative malperfusion (era 1, 45.8% vs era 2, 55.8%; P = .034), and higher German Registry for Acute Aortic Dissection Type A risk scores (era 1, 18.8% [SD, 10.8%] vs era 2, 22.1% [SD, 14.4%]; P = .004). Surgical strategies evolved, with increased use of total arch procedures (era 1, 5.3% vs era 2, 12%; P = .012), axillary artery cannulation (era 1, 44.2% vs era 2, 80.2%; P < .001), and antegrade cerebral perfusion (era 1, 44.2% vs era 2, 95.8%; P < .001). Operative mortality remained unchanged (era 1, 15.3% vs era 2, 14.0%; P = .7). Multivariable analysis identified axillary cannulation (odds ratio [OR], 0.4; P = .002) associated with improved survival, whereas cardiopulmonary bypass time (OR, 1.009; P < .001) and higher German Registry for Acute Aortic Dissection Type A scores (OR, 1.05; P < .001) were associated with decreased survival. ATAAD surgery has become more complex, with increased use of arch repairs and advanced neuroprotection strategies. Despite an older, higher-risk cohort, surgical outcomes remain stable. Axillary artery cannulation was associated with improved survival.

Surgically implanted microaxial flow pumps (mAFP) are increasingly used for cardiogenic shock treatment. Standard mAFP explantation is performed bedside with a shortening of the vascular prosthesis, which may represent a potential source of infection in future. We analyzed the impact of gentamicin-impregnated collagen sponge (GICS) application in the wound during mAFP explantation on the incidence of prosthetic graft infections. Between 01/2020 and 07/2024, 235 patients underwent bedside full-support mAFP explantation at our institution. Since 11/2022, GICS has been routinely applied in 115 patients, while 120 previously were treated without it. In the GICS-group, after a median follow-up of 221 [24; 351] days, 17 (14.8%) patients developed graft infection, resulting in 0.23 events per patient year (EPPY); surgery was necessary in 16 patients (13.9%). In the control group, after a median follow-up of 399 [113; 654] days, infection occurred in 14 (11.7%) cases, 0.10 EPPY; surgical removal of the graft was necessary in 12 (10%). The GICS-groups presented an increased risk for graft infections: sHR 2.49 [1.11; 5.59], p = 0.027. After propensity score matching for relevant demographic parameters, there was no significant difference in the risk reduction of total graft infections sHR 1.92 [0.79; 4,72], p = 0.15. Local application of GICS did not reduce the risk of access site infections in patients undergoing bedside explantation of mAFP from the graft surgically anastomosed to an axillary artery.

Ultrasound of the temporal and axillary arteries is recommended as the first-line imaging test for suspected giant cell arteritis (GCA), but the additional diagnostic yield of facial artery ultrasound (facUS) remains unclear. In this retrospective study, patients with suspected GCA who underwent standardised ultrasound of the temporal arteries (tempUS) and axillary arteries (axUS) were included if both facial arteries had also been examined. Clinical, laboratory, sonographic and histopathological data were retrieved from the electronic medical records. The diagnostic accuracy of facUS was determined by ROC-curve analysis and 2x2 contingency tables. Patients with and without facial artery involvement were compared by univariate significance tests. Among 69 included patients, 37 were diagnosed with GCA and 32 with other conditions. FacUS-values >0.7 mm were found in 34 patients (26 GCA, 8 non-GCA) and >1.0 mm in 18 patients (17 GCA, 1 non-GCA). When facUS was added to tempUS and axUS, sensitivity increased to 97.3% (+8.1%) but specificity decreased to 65.6% (-18.8%) when a cutoff >0.7 mm was applied. With a cutoff >1.0 mm, diagnostic accuracy changed only marginally. Eleven patients showed negative tempUS but positive facUS results; five of them were ultimately diagnosed with GCA (three of whom had isolated facial artery involvement). FacUS provides limited additional diagnostic yield when added to temporal and axillary artery imaging in suspected GCA but may be performed in selected patients with strong clinical suspicion and negative temporal ultrasound findings.

The Impella 5.5 is microaxial left ventricular assist device (LVAD) implanted most commonly into the axillary artery (AxA). This study aims to investigate the incidence and management of vascular graft infection (VGI) following circulatory support with the Impella 5.5. This is a single-center retrospective analysis of 92 patients who were supported by Impella 5.5 between June 2020 and August 2024. Since November 2023, Dacron graft has been tunneled through the pectoralis major muscle via a separate incision in patients expected to require prolonged support. The graft was trimmed and buried beneath the pectoralis major muscle during explant. Support period was classified as short (≤ 14 days, Group SS) or extended (> 14 days, Group ES). Of the 92 patients, 26 (28.3%) died while on support, Impella was explanted in 66 patients (71.7%): Bridge-to-recovery in 36 (39.1%), bridge-to-durable LVAD in 8 (8.7%), and bridge-to-transplant in 22 (23.4%) including 5 heart and kidney transplant (HKT). Median support duration was 7 [5, 8] days in Group SS (N = 54) and 27.5 [18, 38] days in Group ES (N = 38). No infections were reported in Group SS. Four patients in Group ES who underwent HKT experienced VGI following 39, 47, 51, and 85 days of support. Two patients with tunneled grafts required patch repair of AxA, while the remaining two patients with non-tunneled grafts required extensive extra-anatomical bypass. Approximately 10% of patients requiring extended support developed VGI. Heart transplant recipients with a high risk of infection such as extended support or HKT will benefit from a comprehensive approach for early diagnosis and therapeutic intervention.

Left ventricular (LV) unloading during veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is essential for managing refractory low cardiac output after complex cardiac surgery. However, direct LV venting is associated with an increased risk of intracardiac thrombosis, particularly when anticoagulation is delayed. A 69-year-old woman with hypertrophic cardiomyopathy and severe left ventricular outflow tract obstruction presented with exertional dyspnea. Echocardiography showed severe mitral regurgitation with marked annular calcification, moderate aortic regurgitation, and systolic anterior motion of the mitral valve. She underwent complex cardiac surgery including septal myectomy, aortic and mitral valve replacement with bioprostheses, and tricuspid annuloplasty. Intraoperative rupture at the anterior mitral commissure required re-clamping, patch repair, and reimplantation of the prostheses. Prolonged cardiopulmonary bypass led to postoperative circulatory failure, necessitating VA-ECMO via the right axillary artery and femoral vein, with left ventricular venting through the right superior pulmonary vein. On postoperative day 4, ECMO was successfully weaned after recovery of contractility; however, the patient developed acute pulmonary edema and cardiogenic shock within hours, prompting urgent ECMO reinstitution. Transesophageal echocardiography on day 9 revealed thrombotic obstruction of the mitral bioprosthesis, confirmed intraoperatively. Both prosthetic valves and the left ventricle were covered with extensive white and red thrombi, which were completely removed. Cardiac function recovered after reoperation, and ECMO was successfully discontinued. Despite subsequent bilateral cerebral infarctions, the patient survived and was gradually weaned from mechanical ventilation at 1-month follow-up. Thrombotic complications in patients supported with VA-ECMO after valve replacement result from multiple interacting factors, including surgical trauma, prosthetic material, altered flow dynamics, and delayed anticoagulation. This case highlights the diagnostic challenges of assessing prosthetic valve function during VA-ECMO and underscores the need for individualized decisions regarding LV unloading strategies and anticoagulation management. Careful ECMO weaning and close echocardiographic surveillance may help reduce the risk of catastrophic valve-related complications.

Emergency Hybrid Treatment of a Traumatic Left Axillary Artery Injury Resulting from a Shoulder Dislocation

Shoulder dislocation is one of the most common joint dislocations encountered in emergency departments, but vascular complications are rare and often underrecognized. Pseudoaneurysms of the thoracoacromial artery, a branch of the axillary artery, are extremely uncommon and may present with subtle symptoms, delaying diagnosis. An 82-year-old woman with a history of habitual anterior shoulder dislocation presented with a 10-day history of progressive pain and swelling in the left shoulder. She was on edoxaban for atrial fibrillation. Examination revealed localized tenderness and swelling without neurological deficits. Computed tomography angiography showed a 30 × 35 × 35mm pseudoaneurysm arising from the acromial branch of the thoracoacromial artery. Endovascular embolization was performed using a proximal oxidized regenerated cellulose sheet placement followed by injection of N-butyl cyanoacrylate and Lipiodol due to the risk of coil migration into the joint space. The procedure achieved complete exclusion of the lesion. At three-month follow-up, the patient remained asymptomatic with preserved left upper limb function. Computed tomography angiography demonstrated the pseudoaneurysm remains excluded. Although rare, pseudoaneurysms of the thoracoacromial artery can occur after repeated shoulder dislocation and reduction, especially in elderly patients on anticoagulation therapy. Early recognition through imaging and prompt endovascular intervention can prevent serious vascular and neurological complications.

The purpose of this study was to assess the safety and efficacy of aortic cannulation in comparison with right axillary artery (RAX) cannulation. Between 2018 and 2023, 267 and 364 patients underwent aortic or axillary cannulation for aortic repair for acute type A aortic dissection (ATAAD), respectively. Clinical features and outcomes were compared after inverse probability of treatment weighting was stabilized. In the original cohort, patients in the aortic group had higher incidences of innominate artery (IA) dissection (59.6% vs. 45.1%, p<0.001), RAX dissection (13.9% vs. 4.7%, p<0.001), and right common carotid artery (RCCA) dissection (42.7% vs. 13.7%, p<0.001). After weighting, baseline characteristics were well balanced, resulting in a pseudo-cohort of aortic (n=265) vs. RAX (n=357) patients. Aortic cannulation was associated with a lower rate of cannulation-related complications (0.4% vs. 3.5%, p=0.011). In-hospital mortality (8.3% vs. 6.1%, p=0.346) and stroke rates (4.1% vs. 5.8%, p=0.383) were comparable between groups. The aortic group experienced lower rates of reoperation for bleeding (8.0% vs. 2.3%, p=0.001) and extracorporeal membrane oxygenation use (5.0% vs. 2.0%, p=0.046). Mid-term survival did not differ significantly before (p=0.849) or after weight stabilization (p=0.345). Direct aortic cannulation in ATAAD provides in-hospital and mid-term outcomes that are not statistically different from those with axillary cannulation. Aortic cannulation offers an alternative to axillary cannulation, especially for patients with IA/RAX/RCCA dissection.

Aim This study investigated the gross anatomical variability in the formation of the median nerve and evaluated its clinical and surgical implications. The research aimed to observe variations in median nerve root formation, compare differences between sides and genders, and to understand the embryological basis of these variations. Materials and methods A cadaveric investigation was conducted on 60 upper limbs (ULs) from 30 embalmed adult cadavers (15 males and 15 females). An infraclavicular approach was used for dissection, following standard dissection protocols. The number of roots forming the median nerve, along with their relationship to the axillary artery, was documented and analysed. Statistical analysis included chi-square and Fisher's exact tests to correlate findings with age, gender, and laterality. A p-value of less than 0.05 was considered statistically significant. Results Significant variations in median nerve formation were observed in 21 (35%) of specimens. The classic two‑root pattern was present in 39 (65%) of limbs. Three‑root contributions occurred in 17 (28.33%) of cases, predominantly in males. Four‑root contributions were identified in three (5%) of specimens, while single‑root formation was observed in one (1.67%). Only one (1.67%) specimen demonstrated an absent musculocutaneous nerve, with compensatory median nerve innervation to the anterior arm muscles. Gender showed a statistically significant association with root variations, with males exhibiting a higher incidence of contributions from multiple roots. Conclusion Variations in median nerve formation are relatively common and clinically significant. The diversity of morphological patterns necessitates heightened awareness among surgeons, anaesthesiologists, and neurologists. Understanding these anatomical variations is essential for preventing iatrogenic injuries during surgical procedures, ensuring successful regional anaesthesia, and for accurately interpreting atypical neurological presentations.

We report a 13-year follow-up of an infant with severe Kawasaki disease complicated by bilateral axillary artery aneurysms. Right-sided occlusion led to upper limb hypoplasia, while progressive changes in the contralateral aneurysm produced unilateral digital clubbing. This unique combination of contralateral limb hypoplasia and unilateral clubbing, documented through serial imaging, morphometric measurements, and microvascular assessment, highlights how long-term arterial flow disturbances can result in asymmetric peripheral outcomes. This case underscores the need for extended vascular screening in severe Kawasaki disease.

Sjögren's disease (SjD) is a chronic systemic autoimmune disorder primarily affecting the exocrine glands, while Takayasu arteritis (TAK) is a large-vessel vasculitis involving the aorta and its major branches. Although SjD frequently overlaps with other autoimmune diseases, its coexistence with TAK has been reported only rarely. A 47-year-old Turkish woman with seropositive SjD presented with constitutional symptoms, upper extremity claudication, and asymmetric peripheral pulses. Laboratory evaluation revealed elevated inflammatory markers while antiphospholipid antibodies were negative. Computed tomography angiography demonstrated stenotic lesions and vessel wall thickening involving the left subclavian, axillary, carotid, and brachiocephalic arteries. Additional positron emission tomography/computed tomography showed increased vascular uptake consistent with active large-vessel inflammation. Based on clinical, laboratory, and imaging findings, the patient fulfilled the criteria for TAK. Treatment resulted in marked clinical improvement and normalization of inflammatory markers, with sustained remission during a 2-year follow-up period. The coexistence of SjD and TAK is exceptionally rare, with only a limited number of cases reported to date. This case represents the first reported Turkish patient and adds to the growing evidence that large-vessel vasculitis should be considered in SjD patients who develop unexplained vascular or systemic inflammatory features.

Most existing research on breast vasculature has focused on autopsy findings or imaging analyses in patients with breast hypertrophy, while investigations specifically targeting augmentation candidates remain limited. To delineate the breast arterial anatomy in Asian women with small breasts using magnetic resonance imaging (MRI), thereby providing an anatomical basis for surgical approach selection in clinical practice. We retrospectively reviewed preoperative contrast-enhanced MRI scans from 47 women scheduled for breast augmentation and postoperative contrast-enhanced MRI scans from 38 women. The study evaluated the location and characteristics of the internal thoracic vein (ITV) and regional arteries and compared the number of identifiable arterial branches across different surgical incision sites. As per ITV bifurcation, two anatomical variants were observed. Although 55.3% of type I ITVs were bifurcated, 44.7% of type II ITVs were not bifurcated. The breast received its blood supply from the internal thoracic artery branches (ITA, 100%), axillary artery branches (100%), anterior intercostal artery branches (70.2%), and supra-thoracic artery branches (14.9%). Two blood supply patterns were also observed, in which 83.0% of the breasts had a circular anastomotic pattern dominated by ITA or lateral breast artery, while 17.0% disclosed an unclosed loop pattern directed to the nipple. Moreover, we noticed a significant difference between the number of breast vessels with various incisions (p<0.05). Breast-enhanced MRI techniques can provide valuable data about the breast region's blood supply. Based on our anatomical analysis, our study suggests that the inframammary approach may be a safer option. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Inadvertent guidewire retention is an uncommon but potentially serious complication most often described in the context of central venous catheterization, and reports involving arterial access are exceptionally rare. This report describes two cases of inadvertent guidewire retention following radial artery cannulation performed using the Seldinger technique for intraoperative hemodynamic monitoring. In both cases, arterial cannulation was indicated because of complex (and possibly prolonged) surgical procedures with a risk of clinically significant blood loss, thereby necessitating continuous beat-to-beat arterial pressure monitoring. The presumed embolization mechanism involved advancement of the catheter while the pre-attached proximal cap remained in place, thereby preventing the guidewire from exiting proximally and ultimately leading to intravascular displacement of the wire. In the first case, the event remained unrecognized until the patient developed forearm pain, reduced radial and ulnar pulses, and sensory changes to the affected upper extremity several weeks postoperatively. Imaging revealed a retained guidewire extending from the radial artery to the axillary artery, requiring surgical intervention for retrieval. In the second case, the inadvertently retained guidewire was found incidentally on a routine chest radiograph eighteen days postoperatively. These cases illustrate that guidewire retention, albeit rare, can occur during arterial cannulation by the Seldinger technique and shares the same human-factor vulnerabilities long recognized in central venous access-related guidewire retention, including distraction, incomplete preparation and loss of wire control. In response, several system-level safety measures were implemented, including explicit “wire in hand” confirmation before catheter advancement, the use of wire length markers, mandatory removal of manufacturer attached catheter caps prior to insertion, optional sterile forceps control of the guidewire, multidisciplinary verification, and mandatory documentation of guidewire retrieval. These events reinforce the need for robust safety barriers across all procedures using the Seldinger technique to prevent guidewire retention and enhance procedural safety.

External outflow graft obstruction is an uncommon late complication in patients supported with a fully magnetically levitated left ventricular assist device. Progressive extrinsic compression of the outflow graft can impair pump performance and lead to symptomatic deterioration, requiring intervention to restore graft patency. This video tutorial presents a hybrid procedure combining surgical transaxillary access with endovascular stent implantation for treatment of external outflow graft obstruction when transfemoral access is not feasible. A 72-year-old woman with ventricular assist device support presented with exertional dyspnoea. Imaging demonstrated a persistent external narrowing of the outflow graft distal to the cannula, and invasive assessment confirmed a significant pressure gradient. Severe kinking of the femoral vessels excluded conventional femoral access. After induction of general anaesthesia, the axillary artery was exposed through an infraclavicular incision and accessed under direct vision. A vascular sheath was introduced, allowing retrograde advancement of guidewires across the stenotic graft segment. Two overlapping balloon-expandable covered stents were deployed under fluoroscopic guidance to restore luminal diameter and antegrade flow. Completion angiography confirmed satisfactory stent expansion and improved device flow.

The purpose of our multicenter study was to compare the outcome (left subclavian artery [LSA] patency and reintervention) of carotid-subclavian bypass (distal anastomosis supraclavicular) vs carotid-axillary bypass (distal anastomosis infraclavicular), as well as analyzing and comparing possible complications such as phrenic nerve injury and lymph leakage. This multicenter retrospective, observational study included a total of 238 patients who underwent open procedures involving the carotid-axillary bypass (CA) (n = 51) or carotid-subclavian bypass (CB) (n = 187) between January 2011 and December 2022. The mean age of the patients was 64.2 ± 0.8 years (CA, 64.9 ± 1.6 vs CS, 64.07± 0.9). The mean follow-up was 19.4 ± 2.4 months. The most common diagnosis for open LSA revascularization was debranching owing to landing zone preparation during thoracic endovascular aortic repair for aortic aneurysm (n = 100 [42%]) and aortic dissection (n = 81 [34%]). Forty patients (16.8%) were operated owing to a symptomatic occlusion of the subclavian artery. Postoperative complications such as stroke, laryngeal nerve palsy, myocardial infarct, in-hospital mortality, and 30-day bypass occlusion did not differ between the groups. Only patients with the CS experienced postoperative phrenic nerve injury (P = .002) and lymphatic leakage (P = .039). A comparison of bypass-related reintervention between the patients showed no significant difference between the groups (P = .735). The open surgical revascularization of LSA using the axillary artery as the distal bypass target is a safe alternative to traditional CS. It requires a more superficial approach and reduces the incidence of well-known complications such as phrenic nerve affection and lymphatic leakage.

Regional anesthesia techniques for upper limb surgery continue to evolve to improve block reliability while minimizing approach-specific complications. This narrative review evaluates the efficacy and safety of the costoclavicular brachial plexus block, a modified infraclavicular approach that targets the clustered cords of the brachial plexus lateral to the axillary artery. The objective is to synthesize current evidence on clinical performance, analgesic outcomes, and complications in upper limb procedures. A structured literature review of studies published between 2015 and 2025 was conducted using major medical databases, including randomized trials, observational studies, systematic reviews, and relevant anatomical investigations. The evidence demonstrates that the costoclavicular block provides reliable surgical anesthesia and postoperative analgesia for distal and intermediate upper limb procedures, with high success rates and predictable onset under ultrasound guidance. Continuous catheter techniques further extend its analgesic utility. A consistent and clinically significant finding is the lower incidence of hemidiaphragmatic paralysis compared with interscalene and supraclavicular blocks, supporting its use in patients with limited respiratory reserve. Complication rates, including vascular puncture and neurological injury, are low and comparable to other infraclavicular techniques. Although the block alone may not provide complete anesthesia for extensive shoulder surgery, it offers a safe, efficient, and diaphragm-sparing alternative for a wide range of upper limb procedures. This review supports the costoclavicular approach as an important component of contemporary, anatomy-based regional anesthesia practice.

We discovered a variation in the branching pattern of the right axillary artery during routine dissection of an approximately 60-year-old male cadaver for postgraduate and undergraduate medical students at the postgraduate institute of ayurveda dr sarvepalli radhakrishnan rajasthan ayurved university Jodhpur. The second part of the axillary artery gave rise to thoracoacromial artery and a shared trunk that split into the subscapular and lateral thoracic arteries. The anterior and posterior circumflex humeral arteries were formed by the third part of the right axillary artery. Variations in the branching pattern of the axillary artery are essential for cardiovascular surgeons doing interventional or diagnostic operations.

Postoperative complications in patients with acute type A aortic dissection (ATAAD) significantly affect their prognosis. This study investigates the association between cardiopulmonary bypass(CPB) weaning time and postoperative adverse outcomes in patients with aortic dissection who underwent total arch replacement combined with stented elephant trunk implantation. Patients diagnosed with ATAAD who underwent surgical repair between June 1, 2015, and June 1, 2024, were retrospectively enrolled. CPB weaning time was recorded for each patient. Univariate and multivariate logistic regression analyses were performed to evaluate the association between CPB weaning time and postoperative adverse outcomes, including death, stroke, and other adverse outcomes. Subgroup analyses were also conducted. Receiver operating characteristic (ROC) curve analysis was used to determine the optimal cutoff value of CPB weaning time. Kaplan–Meier survival analysis and log-rank tests were subsequently applied to compare survival between groups stratified by the cutoff value. A total of 475 patients were included in the analysis. Prolonged CPB weaning time was significantly associated with increased postoperative in-hospital death (Odds Ratio[OR]: 1.05; 95% Confidence Interval[CI]: 1.02–1.07; P < 0.001) and stroke (OR: 1.02; 95% CI: 1.00–1.03; P = 0.016), but not with other outcomes. The association between CPB weaning time and postoperative in-hospital death remained consistent across subgroups, whereas its association with stroke was influenced by sex, history of coronary heart disease, coronary artery bypass grafting (CABG), axillary artery cannulation, and femoral artery cannulation. The area under the curve (AUC) values of CPB weaning time for predicting postoperative in-hospital death and stroke were 0.844 (95% CI: 0.790–0.899) and 0.670 (95% CI: 0.606–0.734), respectively, with an optimal cutoff value of 90 min. When patients were stratified by this cutoff, a statistically significant difference in short-term survival was observed between the two groups, whereas no significant difference was found in mid-term survival. CPB weaning time is associated with postoperative death and stroke in patients with ATAAD undergoing total arch replacement combined with stented elephant trunk implantation. It is also associated with poor short-term survival but not with mid-term survival, and serve as a predictor of early postoperative risk of mortality in this population.

Introduction: Subclavian artery (SCA) aneurysms are rare, accounting for less than 1% of peripheral aneurysms. Repair is indicated due to the risk of complications. Methods: The electronic medical records in our institution were reviewed and the case of a patient with large right SCA is presented.Results: An 80 year-old female, with complex medical history, presented with a large right SCA aneurysm. She was deemed high risk for open repair and underwent innominate and common carotid artery stent graft placement, embolization of the sac, and carotid to axillary artery bypass. Her clinical course was complicated by an atheroembolic multiterritorial stroke, and she was found to be clopidogrel resistant. She was discharged to a rehabilitation facility and was recovering well at 3 months after surgery.Conclusion: Detailed and careful pre-operative planning, as well as familiarity with the different surgical approaches is necessary for the best outcomes.