Level Of Bifurcation Research Articles

Intraoperative Observation of the Proper Digital Nerves in Wassel–Flatt Type Ⅳ Radial Polydactyly

The aim of the study was to present the intraoperative findings of the relevant digital nerves of the duplicated thumbs in an excision and reconstruction procedure for the Wassel-Flatt type Ⅳ radial polydactyly. The study was conducted on patients with Wassel-Flatt type IV radial polydactyly who underwent excision and reconstruction between 2018 and 2021 at our institution. The ulnar digital nerve of the radial thumb and the radial digital nerve of the ulnar thumb were identified and traced intraoperatively. The level of the bifurcation of the nerves and abnormal findings were documented. A total of 123 hands in 119 patients were included in this study. In 114 hands, the bifurcation of the nerves was located within 1 cm of the metacarpophalangeal flexion crease. The radial digital nerve to the ulnar thumb was abnormally compressed in deep fascial tissue in 7 of these 114 hands. In 5 hands, the level of bifurcation was more than 1 cm proximal to the crease. No radial digital nerve to the ulnar thumb was identified in the remaining 4 hands. Although rare, abnormal nerve compression of the digital nerve may exist in duplicated thumbs of Wassel-Flatt type IV radial polydactyly. In an excision and reconstruction procedure, we suggest that the bifurcation of the nerves should be identified before the nerve to the radial thumb is excised to avoid injuring the nerve to the main ulnar thumb.

Variations of Bifurcation of the Common Carotid Artery, and Origin of Superior Thyroid Artery, in Sudanese: A Cadaveric Study

Background: Knowledge of the bifurcation level of the common carotid artery (CCA) is important during surgery, mummification, and radiological studies. This study aim to evaluate the anatomical variations in the bifurcation level of CCA, and the origin of the superior thyroid artery (STA), in Sudanese populations. Their knowledge reduces risk during surgery and helps in arterial ligation. Materials and Methods: 30 neck cadaveric specimens were evaluated on sides, using natural anatomical tools and methods for the anatomical studies. Results: The bifurcation of CCA was found at 36.7% at the level of the upper border of thyroid cartilage (TC), 61.7% above, and 1.6% below. No big differences were found in carotid bifurcation on both sides. The right side showed 30% were normal, 66.7 % high, and 3.3% were low-level bifurcation, left showed 43.3% were normal, 56.7% high, and no low level of bifurcation was observed. Origin of STA either from external 50% or bifurcation 46.7% was nearly about the same, with a few incidences 3.3% from the common carotid. Significance differences were observed in origin STA between both sides, on the right the artery commonly originates from external, and on the left commonly from the bifurcation. Conclusion: CCA bifurcates at a higher level in Sudanese, with no big difference in carotid bifurcation on both sides. Statistically, a significant difference was found in the origin of STA on both sides. Recommendation: higher bifurcation of CCA, and side variations in origin of STA, should be put into consideration during surgery and radiology.

Anatomical variations in the origin of the superior thyroid artery

Superior thyroid artery (STA) is first and lowest branch of external carotid artery (ECA) and it supplies thyroid, parathyroid, upper larynx and neck region. The STA origins either from ECA, common carotid artery (CCA) or its bifurcation level. Various researchers have reported differences in its origin. The STA commencing from the ECA is comparatively more in Indian and Ethiopian but its derivation from CCA bifurcation point is more in Turkey and Korean. Origin of STA in relative to upper border of thyroid cartilage is used as a landmark. The CCA bifurcates into external and internal carotid arteries at same level and occasionally bifurcates at a higher or lower level than its usual site. Origin of STA from CCA is associated with high bifurcation and its origin from the ECA is related with the low CCA division. Comparatively STA origin from CCA or its bifurcation level is more on right side. The CCA developed from third aortic arch and any alteration in development of aortic arches might also contribute to these variations. The STA is an artery of abundant clinical significance and it is recommended to do detailed study of its origin, course, branches, size, and positional relation with the external laryngeal nerve, hyoid bone and thyroid cartilage. Understanding of these variations is immense importance in academic and clinical arena for planning and performing surgical procedures in neck region.

A « tipical » but rare cause of neck pain

•Not available for clinical flashcards. A 34-year-old man with medical history of familial deafness presented to the emergency department for an acute left cervicalgia and painful jaw for one week. He reported a context of recent physical effort because of house moving. He had already performed a cervical echography, which showed a thickening of the wall of the left common carotid artery (panel A) without disturbance of the vascular flow on Doppler (panel B). At presentation, vital parameters were normal with symmetrical blood pressure measurement, and no fever. Clinical examination, in particular neurological examination, was normal. Electrocardiogram was unremarkable. Biological tests showed a normal C-reactive protein value (4.4 mg/L), normal troponin, and search was negative for anti-neutrophil cytoplasmic antibodies, anti-nuclear antibodies (titer at 1:80) and anti-DNA antibodies. Finally, cervical angio-CT-scan eliminated a carotid dissection and revealed a perivascular infiltration surrounding the left common carotid artery with a thickened carotid wall (panel C). All these elements were suggestive of transient perivascular inflammation of the carotid artery (TIPIC) syndrome, also known as carotidynia or Fay syndrome (Image). Fay first described carotidynia in 1927 as an atypical neuralgia. Historically characterized by the association of unspecific clinical signs like tenderness and pain at the level of the carotid bifurcation, this entity was controversial and it is still unrecognized as a distinct pathology [[1]Lecler A Obadia M Savatovsky J Picard H Charbonneau F Menjot de Champfleur N et al.TIPIC syndrome: beyond the myth of carotidynia, a new distinct unclassified entity.Am J Neuroradiol. 2017; 38: 1391-1398Crossref PubMed Scopus (41) Google Scholar]. A recent multi-centric cases series of 47 patients proposed a new definition based on four criteria: a) presence of acute pain overlying the carotid artery, which may or may not radiate to the head, b) eccentric perivascular infiltration on imaging, c) exclusion of another vascular or non-vascular diagnosis with imaging, d) improvement within 14 days either spontaneously or with anti-inflammatory treatment [[1]Lecler A Obadia M Savatovsky J Picard H Charbonneau F Menjot de Champfleur N et al.TIPIC syndrome: beyond the myth of carotidynia, a new distinct unclassified entity.Am J Neuroradiol. 2017; 38: 1391-1398Crossref PubMed Scopus (41) Google Scholar]. The pathogenesis of the TIPIC syndrome remains unclear, cardiovascular, inflammatory or autoimmune origins are suspected [[2]Taniguchi Y. Horino T. Hashimoto K. Is carotidynia syndrome a subset of vasculitis?.J Rheumatol. 2008; 35: 1901-1902PubMed Google Scholar]. The two major differential diagnosis for carotid involvement are carotid dissection and vasculitis, notably Takayasu's arteritis or giant cell arteritis. Only one study reported a histologically evaluation and found proliferation of small blood vessels, low-grade of lymphocytic infiltration and early fibrosis. These histological finding were not specific but were different from the histological aspect of abscess wall, granulation tissue or vasculitis like giant cells arteritis [[3]Upton P.D. Smith J.G. Charnock D.R. Histologic confirmation of carotidynia.Otolaryngol Head Neck Surg. 2003; 129: 443-444Crossref PubMed Scopus (54) Google Scholar]. Our patient did not receive any treatment and he recovered in seven days. TIPIC syndrome is a rare but not serious condition, which usually improves spontaneously. However, it is important to recognize in order to avoid over-medicalization.

Anatomy matters: The role of the subject-specific respiratory tract on aerosol deposition — A CFD study

The COVID-19 pandemic is one of the greatest challenges to humanity nowadays. COVID-19 virus can replicate in the host’s larynx region, which is in contrast to other viruses that replicate in lungs only, i.e. SARS. This is conjectured to support a fast spread of COVID-19. However, there is sparse research in this field about quantitative comparison of virus load in the larynx for varying susceptible individuals. In this regard the lung geometry itself could influence the risk of reproducing more pathogens and consequently exhaling more virus. Disadvantageously, there are only sparse lung geometries available. To still be able to investigate realistic geometrical deviations we employ three different digital replicas of human airways up to the 7th level of bifurcation, representing two realistic lungs (male and female) as well as a more simplified experimental model. Our aim is to investigate the influence of breathing scenarios on aerosol deposition in anatomically different, realistic human airways. In this context, we employ three levels of cardiovascular activity as well as reported experimental particle size distributions by means of Computational Fluid Dynamics (CFD) with special focus on the larynx region to enable new insights into the local virus loads in human respiratory tracts. In addition, the influence of more realistic boundary conditions is investigated by performing transient simulations of a complete respiratory cycle in the upper lung regions of the considered respiratory models, focusing in particular on deposition in the oral cavity, the laryngeal region, and trachea, while simplifying the tracheobronchial tree. The aerosol deposition is modeled via OpenFOAM\\protect \\relax \\special {t4ht=®} by employing an Euler-Lagrangian frame including steady and unsteady Reynolds Averaged Navier–Stokes (RANS) resolved turbulent flow using the k-ω-SST and k-ω-SST DES turbulence models. We observed that the respiratory geometry altered the local deposition patterns, especially in the laryngeal region. Despite the larynx region, the effects of varying flow rate for the airway geometries considered were found to be similar in the majority of respiratory tract regions. For all particle size distributions considered, localized particle accumulation occurred in the larynx of all considered lung models, which were more pronounced for larger particle size distributions. Moreover, it was found, that employing transient simulations instead of steady-state analysis, the overall particle deposition pattern is maintained, however with a stronger intensity in the transient cases.

Changes in the Relative Displacement between the Supra-Aortic Branches with Age

This study aimed to determine the normal ranges for the height and deflection angle of the aortic arch and the displacement distances between the supra-aortic branches in relation to age, sex, body mass index (BMI), and body surface area (BSA) in adults without aortic disease using non-contrast chest computed tomography (CT). The CT scans of 700 patients were analyzed. We measured the height and deflection angle of the aortic arch based on the lower level of the pulmonary artery bifurcation. The displacement distances between the supra-aortic branches in the coronal and sagittal planes were measured, and the deflection angles between these branches were calculated. Multiple linear regression analysis was used to investigate the associations of age, sex, BMI, and BSA with these aortic arch parameters. The height of the aortic arch was significantly higher (74±15mm vs. 65±12mm, P<0.001) and the left-posterior displacement distance of the left subclavian artery (LSA) to the innominate artery (IA) was greater in men than that in women. The height and deflection angle of the aortic arch increased with age. The distance by which the LSA was shifted to the left posterior of the left common carotid artery and to the left of the IA increased with age. The normal aging process is accompanied by morphological changes in the aortic arch and relative displacement between the supra-aortic branches. Identifying these parameters could lead to a comprehensive understanding of the anatomy and morphology of the aortic arch.

Comparing the crown and root metric properties of double-rooted and single-rooted mandibular canine teeth.

To compare the crown and root metric properties of two- and single-rooted/multi-canal mandibular canines (MnCn) with single-rooted/single-canal MnCn. Cone-beam computed tomography images of 1000 patients (500 women and 500 men) with both right and left MnCn were analyzed. First, the root and canal morphologies of all teeth were examined. Then, the teeth were divided into three groups; (a) 2-rooted, (b) 1-rooted and multi-canals, (c) 1-rooted and single-canal. Crown lengths/sizes and tooth lengths were compared between the three groups. Statistical analyses were performed using Chi-square, one-way ANOVA, Welch, post hoc pairwise comparison, and independent sample t-tests. The significance level was set at 5%. Of all the teeth, 2.35% were 2-rooted, and 6.3% were 1-rooted/multi-canal. The frequency of double roots was higher in women (p < 0.05). Double-rooted teeth had longer crown lengths but shorter tooth lengths than single-rooted teeth (p < 0.05). In 2-rooted teeth, buccal and lingual root lengths were similar, root bifurcation levels were mostly at the mid-root, and the mean distance of the bifurcation points of the canals to the cemento-enamel junction was 4.09mm. Double-rooted teeth were mostly observed unilaterally. Since 2-rooted MnCn do not differ significantly from other teeth in terms of crown sizes, it is not possible to differentiate between single- vs. double-rooted MnCn based on clinical examination.

ANALYSIS OF THERMAL CONDUCTIVITY OF DAMAGED TREE-LIKE BIFURCATION NETWORK WITH FRACTAL ROUGHENED SURFACES

Tree bifurcation network has always been a hot issue concerning scientists all over the world. However, the research on the heat conduction properties of damaged tree-like bifurcation networks is insufficient, and many issues remain unsolved. Therefore, this paper systematically studies the heat conduction phenomenon of a new damaged tree-like bifurcation network with fractal roughened surfaces (FRS), and derives the equivalent thermal conductivity of damaged network. According to the study, the dimensionless thermal conductivity (DTC) shows a downward trend with an increase in roughness. In addition, it can be seen that an increase in the number of damaged channels leads to a downward trend in the optimal thermal conductivity, but a slow upward trend in the critical diameter. Another interesting phenomenon is that the factors leading to the change in the optimal thermal conductivity do not include the total number of bifurcation levels, bifurcation number or the fractal dimension of length distribution. The model established in this paper does not contain any empirical constants to ensure that each parameter has its physical significance, revealing the heat transfer mechanism of tree-like bifurcation network more profoundly.

An assessment of branching asymmetry of the tracheobronchial tree

The tracheobronchial tree is commonly seen to have a systematic branching symmetry, despite being known to have an asymmetrical design. Branching asymmetry allows for uniform airflow and provides robustness against the morphogenesis-related size variability. Here, a constructal approach is used to tracheobronchial tree analysis, and a general model based on entropy generation during breathing process is provided, which holds with asymmetric characteristics of the tree, and the change for inhaling and exhaling air. In contrast to traditional models available in the literature, the entropy generation of inspiration and expiration processes is compared for symmetry and asymmetric designs. This approach unravels the fundamental consequences of asymmetric constraint in the process of breathing and provides justification for the tracheobronchial tree having the same number of bifurcation levels as optimized symmetrical trees.

Anatomic Variation of the Sciatic Nerve: A Study on the Prevalence, and Bifurcation Loci in Relation to the Piriformis and Popliteal Fossa.

To examine and identify sciatic nerve variations in relation to the piriformis muscle, its prevalence, pattern and the course of its bifurcation loci. Twenty-eight formalin fixed male cadavers comprising 56 lower limbs were used for this study. Dissection of the gluteal region and posterior compartment of the thigh was conducted to expose the sciatic nerve. Variations in the sciatic nerve anatomy, their relationship to the piriformis muscle and points of bifurcation, and other observable features were noted and recorded. Fifty-two lower limbs (93%) showed normal anatomy of the sciatic nerve. Four regions (7.1%) showed variations in the morphology of the sciatic nerve. Of these, one (1.8%) showed a variation of the sciatic nerve with the piriformis muscle. This single case showed a common peroneal nerve emerging on the left between the heads of a double piriformis muscle - a variant not described in the original Beaton and Anson classification, with the tibial nerve deep to the muscle. In two other limbs, the sciatic nerves showed a normal relationship with the piriformis, but had variations in the bifurcation loci (bilateral). The divisions were in upper third and middle third of the right and left thighs respectively. Knowledge of the level of bifurcation and distribution of the sciatic nerve and its location is important. This nerve is commonly encountered by neurologists, orthopaedics, and anaesthesiologists. The uncommon anatomical findings described are relevant to surgeons to enable them to perform efficient surgical procedures and avoid errors.

Fast parameterized fractal modeling of active heat transfer channel

This paper presents a fast parameterized modeling method for fractal channel and constructs a unified parametric model for Y-shaped, V-shaped, T-shaped fractal channels. This parametric model establishes the relationship between multiple parameters (levels ratio, bifurcation level, pipe diameter ratio, bifurcation angle, aspect ratio) and performance of fractal channel. Parameterized modeling method can reduce repetitive workload and time, improve efficiency. Meanwhile, parametric model allows for a more comprehensive study, and it is important for reduce the occasionality of results. Using the parameterized modeling method, the aspect ratio and fractal channel type are numerically studied. The numerical study of the aspect ratio reveals that with the increase of aspect ratio, Nusselt number decreases, the peak temperature rises and then falls, and the pressure drop first decreases and then increases. The numerical study of fractal channel types shows that the V-shaped channel has the best cooling performance and Y-shaped channel has the best flow performance. Compared to the T-shaped channel, Nusselt number of V-shaped channel increases by 11.29%∼19.74%, the thermal resistance of V-shaped channel decreases by 8.18%∼19.73%, and the pressure drop of Y-shaped channel decreases by 51.04%∼61.75%. The fractal channel parametric model can be applied not only for parameter studies, but also for parameter optimization.

Improving rating curve accuracy by incorporating water balance closure at river bifurcations

Accurate discharge records are essential for flood frequency analyses, hydraulic model calibration and flood forecasting. Discharge records are often obtained via a transformation of water levels to discharges using a rating curve. For accurate rating curves, a physical basis is important, particularly in the extrapolation domain towards extreme discharges. In this study, physical processes and constraints are incorporated in a rating curve model: water balance closure at a bifurcation and bed level degradation. The aim is to assess the effect of incorporating these physical processes and constraints for rating curves at two bifurcations of the Rhine river in the Netherlands. Intermittent gaugings are available for a 31 year period at these bifurcations. Bayesian inference and Markov Chain Monte Carlo sampling is used to estimate the posterior distributions of the rating curves. If rating curves are constructed independently, they show a large water balance error at bifurcations of up to 10%. Incorporating bed level degradation is required for accurate rating curves as it reduces the residual errors by up to 50%. If explicitly accounting for water balance closure, the water balance error can be reduced to 1%, while residual errors remain equally small. As water balance closure is a physical constraint at a river bifurcation, the rating curves that account for water balance closure are expected to be more physically realistic. Therefore, it is recommended to specifically gauge at river bifurcations and confluences, such that the constraint of water balance closure can be used to improve the accuracy of rating curves and discharge records.

Comprehensive anatomy of the superior hypogastric plexus and its relationship with pelvic surgery landmarks: defining the safe zone around the promontory.

Pelvic surgery carries an inherent risk of autonomic nerve injury leading to genitourinary and bowel dysfunction due to the close proximity of the superior hypogastric plexus (SHP). The aim of this study was to define the detailed anatomy of SHP and identify its relationship with the vascular landmarks and ureters for pelvic autonomic nerve-preserving surgery. A cadaveric study on the detailed anatomy of the SHP was conducted in our surgical anatomy research unit. Between 02/2019 and 10/2019, macroscopic anatomical dissections were performed on 45 fresh adult cadavers (39 male, 6 female). Distances between the SHP, major vascular structures, and other anatomical landmarks were measured. Three types of SHP morphology were observed: mesh (64.8%), single nerve (24.4%), and fiber (10.8%). SHP bifurcation was located inferior to the aortic bifurcation in all cases; however, it was observed cranial to the promontory in 80% of the cases, whereas 18% were caudally and 2% were over the promontory. The closest vessels to the left and right of the SHP bifurcation were the left common iliac vein (LCIV) (86.2%, the mean distance was 8.49 ± 7.97mm) and the right internal iliac artery (RIIA) (48.2%, mean distance was 13.4 ± 9.79mm), respectively. At SHP bifurcation level, the lateral edge of the SHP was detected on the LCIV in 22 cases and on the RIIA in 10 cases for the left and right side of the plexus, respectively. The distance between the SHP bifurcation and the ureter was 27.9mm on the right and 24.2mm on the left. The width of the left (LHN) and right hypogastric nerves (RHN) were 4.35mm and 4.62mm at 2cm below the SHP bifurcation, respectively. LHN was on the vascular structures in 13 cases, whereas RHN in only 1 case, 2cm below the SHP bifurcation. Understanding the location of the SHP, including its relationship with important anatomical landmarks, might prevent iatrogenic injury and reduce postoperative morbidity in the pelvic surgery setting.

Detection of an undescended parathyroid adenoma with 18F-fluorocholine PET/CT

Surgical excision of a parathyroid adenoma (PTA) is the only curative treatment for primary hyperparathyroidism (PHP). The transition from routine bilateral neck exploration to minimally invasive parathyroidectomy has been made possible by preoperative location techniques, including molecular imaging. Here, we present a case of a 76-year-old man with PHP who underwent a [18F]fluorocholine PET/CT scan, which showed a rare undescended PTA at the level of the right carotid bifurcation. After a successful minimally invasive parathyroidectomy, a PTA was confirmed, and the parathyroid hormone level normalized within 24 h. We conclude that it is relevant to locate preoperatively a PTA accurately to assist the surgeon to perform a successful minimally invasive parathyroidectomy.

Increased RV:LV ratio on chest CT-angiogram in COVID-19 is a marker of adverse outcomes

BackgroundRight ventricular (RV) dilation has been used to predict adverse outcomes in acute pulmonary conditions. It has been used to categorize the severity of novel coronavirus infection (COVID-19) infection. Our study aimed to use chest CT-angiogram (CTA) to assess if increased RV dilation, quantified as an increased RV:LV (left ventricle) ratio, is associated with adverse outcomes in the COVID-19 infection, and if it occurs out of proportion to lung parenchymal disease.ResultsWe reviewed clinical, laboratory, and chest CTA findings in COVID-19 patients (n = 100), and two control groups: normal subjects (n = 10) and subjects with organizing pneumonia (n = 10). On a chest CTA, we measured basal dimensions of the RV and LV in a focused 4-chamber view, and dimensions of pulmonary artery (PA) and aorta (AO) at the PA bifurcation level. Among the COVID-19 cohort, a higher RV:LV ratio was correlated with adverse outcomes, defined as ICU admission, intubation, or death. In patients with adverse outcomes, the RV:LV ratio was 1.06 ± 0.10, versus 0.95 ± 0.15 in patients without adverse outcomes. Among the adverse outcomes group, compared to the control subjects with organizing pneumonia, the lung parenchymal damage was lower (22.6 ± 9.0 vs. 32.7 ± 6.6), yet the RV:LV ratio was higher (1.06 ± 0.14 vs. 0.89 ± 0.07). In ROC analysis, RV:LV ratio had an AUC = 0.707 with an optimal cutoff of RV:LV ≥ 1.1 as a predictor of adverse outcomes. In a validation cohort (n = 25), an RV:LV ≥ 1.1 as a cutoff predicted adverse outcomes with an odds ratio of 76:1.ConclusionsIn COVID-19 patients, RV:LV ratio ≥ 1.1 on CTA chest is correlated with adverse outcomes. RV dilation in COVID-19 is out of proportion to parenchymal lung damage, pointing toward a vascular and/or thrombotic injury in the lungs.

Importance of Aortic Bifurcation for Pelvic Radiotherapy in Cervical Cancer Patients

Purpose: Radiotherapy is a major modality for treating cervical cancer patients. Conventionally, superior border of treatment portal in cervical cancer is kept at L4-L5 intervertebral spaces; however, newer concepts suggest that aortic bifurcation should be the determining factor for the superior border. This study aims to observe the level of aortic bifurcation in cervical cancer patients. Methods and materials: A retrospective observational study was conducted in cervical cancer patients undergoing radiotherapy between July 2019 and August 2020 in B.P. Koirala Memorial Cancer Hospital, Bharatpur. Histologically confirmed International Federation of Gynecology and Obstetrics (FIGO) stages II and III carcinoma cervix patients referred for radiation therapy were included in the study. Baseline variables including age group, FIGO stages were noted from the hospital record. Computed Tomography (CT) simulation images were reviewed from the treatment planning system to detect the levels of aortic bifurcations. Results: Total 281 patients of carcinoma cervix were registered for the study with age ranging from 29 years to 87 years and the commonest age group being 51-60. The maximum patients were of stage IIB (46.6%). The aortic bifurcations levels varied from mid L3 to L5-S1 intervertebral space and the commonest level observed was mid L4 vertebra in 70 (24.9%) patients. Conclusion: Anatomical variation in the level of aortic bifurcation, considered as the superior CTV border in pelvic radiotherapy in cervical cancer, demands the conventional superior border, L4-L5 intervertebral space, to be shifted more superior to include common iliac nodes in the treatment field.

Clinical Impact of Computed Tomography Lung Density in Patients with Peripheral Extracorporeal Life Support Receiving Escalation of Mechanical Circulatory Support

<h3>Purpose</h3> Peripheral veno-arterial extracorporeal membrane oxygenation (p-VA-ECMO) is an essential option for patients with cardiogenic shock, whereas several clinical issues remain due to its unphysiological hemodynamic conditions. Lung damage especially due to massive lung congestion is one of the critical complications related to p-VA-ECMO and has been also recognized as a trigger for escalation of mechanical circulatory support (MCS) using left ventricular (LV) venting. However, the prognostic impact of lung damage in patient with p-VA-ECMO has not been fully elucidated. <h3>Methods</h3> This is a single-center retrospective observational study, targeting patients with cardiogenic shock treated with p-VA-ECMO in our institution from 2013 to 2020. Fifty consecutive patients who underwent chest computed tomography (CT) on VA-ECMO followed by escalation to central ECMO with LV venting including LVAD assist devices were enrolled for this study. The average density of lung CT images [Hounsfield unit (HU)] in both upper field at the levels of bifurcation of trachea that indicates lung congestion were measured in all enrolled patients with region-of-interest methods. The primary endpoint of this study was 180-day mortality after escalation to central ECMO. <h3>Results</h3> Twenty-two patients (44%) developed primary endpoint during the follow-up period [169 (48-180) days]. According to the univariate and multivariable Cox proportional hazard analysis, age [hazard ratio (HR), 1.10; 95% confidential interval (CI), 1.05-1.18; <i>p</i> <0.001], ischemic etiology (HR, 2.91; 95% CI, 1.22-6.96; <i>p</i> =0.017) and high lung density (HR, 1.00; 95% CI, 1.00-1.01; <i>p</i> =0.004) were independently associated with the primary endpoint. Furthermore, optimal cutoff value of lung density to predict primary endpoint was determined as -481 HU. The 180-day overall survival rate after MCS escalation for patients with high lung density (≥ -481 HU) was significantly lower than that of patients with low lung density (40.0% vs. 72.0%, respectively, <i>p</i> =0.025). <h3>Conclusion</h3> This study demonstrates the important clinical implications of lung damages assessed by CT lung density as useful predictors of outcomes in patients with p-VA-ECMO requiring escalation of MCS.

Evaluation of the level of carotid bifurcation and the morphology of extracranial internal carotid artery in patients with carotid stenosis by color doppler ultrasound and digital subtraction angiography

Objective: To evaluate the value of color Doppler ultrasound and digital subtraction angiography (DSA) in evaluating the level of carotid bifurcation and the morphology of extracranial internal carotid artery in patients with atherosclerotic carotid stenosis. Methods: The carotid artery examination data of 186 patients with atherosclerotic carotid stenosis who underwent carotid DSA and color Doppler ultrasound in Shanghai Changzheng Hospital from July 2017 to June 2019 were retrospectively analyzed, including 154 males and 32 females, with ages ranging from 36 to 84 (66±8) years old. The correlation between the position of carotid bifurcation and the level of cervical spine, the distance from the position of carotid bifurcation to mandibular angle, the correlation of the level of bifurcation with the length of neck, and the incidence of carotid distortion were analyzed. Results: DSA showed that the most common position of carotid bifurcation was at C3 level on the left [37.3% (56/150)], and at C3-C4 level on the right [33.6% (42/125)], and the highest position was at C2 level on the left, and at C2-C3 levels on the right, while the lowest level on both sides was at C5 level. The incidence of high bifurcation of left carotid artery (C3 and above) was 46% (69/150), which was higher than that of right carotid artery [21.6% (27/125), P<0.001]. The incidence of high carotid bifurcation in men and women was 33.2% (76/229) and 43.5% (20/46), respectively, with no significant difference (P = 0.182). Carotid ultrasound showed that the distance between the left carotid bifurcation and the mandibular angle was (3.0±1.3) cm, which was shorter than that on the right [(3.4±1.2) cm] (P<0.001). The distance between carotid bifurcation and mandibular angle in men and women was (3.2±1.2) cm and (3.3±1.0) cm, respectively, with no significant difference (P = 0.093). There was no significant correlation between carotid bifurcation level and carotid length (right: r = 0.02, P = 0.091; left: r = 0.01, P = 0.927). The incidence of carotid artery distortion was 28.1% (9/32) in women and 15.6% (24/154) in men, with no significant difference (P = 0.091). The incidence of right carotid artery distortion in high bifurcation group was 59.3% (16/27), which was higher than that in non-high bifurcation group [3.1% (3/98)] (P<0.001). Likewise, the incidence of left carotid artery distortion in high bifurcation group was 30.4% (21/69), which was higher than that in non-high bifurcation group [2.5% (2/81)] (P<0.001). Conclusions: The bifurcation position of left carotid artery in patients with atherosclerotic carotid stenosis is higher than that of the right. Patients with high bifurcation of carotid artery are more likely to be complicated with carotid distortion. Preoperative color doppler ultrasound combined with DSA can evaluate the distortion of extracranial carotid artery, thereby providing reference for the selection of surgical methods.

Thoracic cavity-to-cage ratio is a predictor of technical difficulties in minimally invasive esophagectomy

BackgroundTechnical difficulties are occasionally encountered when performing conventional minimally invasive esophagectomy and robot-assisted minimally invasive esophagectomy in patients with a narrow thoracic cavity. Thoracic cavity-to-cage ratio is an indicator of thoracic cavity length. We hypothesized that the thoracic cavity-to-cage ratio could be a predictor of technical difficulties in conventional minimally invasive esophagectomy and robot-assisted minimally invasive esophagectomy. MethodsWe evaluated 340 patients who underwent minimally invasive esophagectomy for esophageal squamous cell carcinoma between April 2010 and March 2021. Thoracic cavity-to-cage ratio was calculated as the diameter of the thoracic cavity to that of the thoracic cage at the brachiocephalic vein, tracheal bifurcation, and inferior right pulmonary vein levels. Moreover, thoracic cavity-to-cage ratio score, which is an indicator of the whole thoracic cavity length based on the thoracic cavity-to-cage ratio at the 3 levels, was defined. The thoracic procedure time was considered an indicator of surgical difficulty. ResultsWe divided the patients into the conventional minimally invasive esophagectomy (n = 295) and robot-assisted minimally invasive esophagectomy (n = 45) groups. The patients in each group were divided into 2 cohorts according to median thoracic procedure time. Based on multivariate analysis, body mass index (P = .0007), clinical N stage (P = .0191), and thoracic cavity-to-cage ratio score (P = .0005) were independent factors for thoracic procedure time in the conventional minimally invasive esophagectomy group. Moreover, thoracic cavity-to-cage ratio at the tracheal bifurcation level (P = .0331) was the only independent factor for thoracic procedure time in the robot-assisted minimally invasive esophagectomy group. ConclusionThoracic cavity-to-cage ratio could be a predictor of technical difficulties in both conventional minimally invasive esophagectomy and robot-assisted minimally invasive esophagectomy.

A cadaveric study of relationship of external carotid artery with reference to adjacent anatomical landmarks

Evaluation of carotid bifurcation level and relationship of External Carotid Artery (ECA) with reference to adjacent anatomical landmarks is important in planning various surgical and radiological procedures related to the carotid arteries. The aim was to study the relationship of External Carotid Artery with reference to Adjacent Anatomical landmarks in cadavers. 60 cadavers - 52 male and 8 female embalmed with 10% formalin were dissected over the period of two years for this study. The distance between the origin and the termination of ECA was found to be in the range of 25–70 mm on the right side and in the range of 25–68 mm on the left side. The distance between the origin of ECA and the carotid tubercle was found to be in the range of 23–50 mm on the right side and in the range of 22–48 mm on the left side. The distance between the origin of ECA and the angle of the mandible was found to be in the range of 18–30 mm on the right side and in the range of 20–32 mm on the left side. The anatomical knowledge of relationship of External Carotid Artery with reference to adjacent anatomical landmarks is helpful for vascular surgeons to plan surgeries and prevent complications during various diagnostic and therapeutic procedures.