Branch Of Femoral Artery Research Articles

A long-term survival model of 40-min deep hypothermic circulatory arrest in rats

Objective To establish a long-term survival model of deep hypothermic circulatory arrest (DHCA) in rats, which could contribute to the research of organ damage mechanism and clinical treatments related to DHCA. Methods Twenty Sprague-Dawley rats were randomly (random number) divided into the sham group (n=10) and DHCA group (n=10). After anesthesia, a 20 G catheter was cannulated in the tail artery for arterial inflow, a multiorificed catheter in the right jugular vein for venous drainage, and a 24G catheter in the branch of left femoral artery for artery blood pressure monitoring. Rats in the DHCA group underwent DHCA procedure for 40 min after brain temperature cooled to 18℃, then rewarmed for 40 min, till the brain temperature were above 34℃. Rats in the sham group were cannulated but did not undergo cardiopulmonary bypass (CPB). Hemodynamic parameters and blood gas analysis were measured for 5 times (pre-CPB, 15 min after CPB, 10 min after rewarming, 40 min after rewarming, and 30 min after CPB). Results One rat in the DHCA group died, and the rest rats survived. The lactate level in the DHCA group after rewarming during operation was significantly higher than that in the sham group (7.84 mmol/L vs 1.93 mmol/L, P<0.05). Conclusions In this study, 40-min DHCA model in rats is characterized by safe and long-term survival. Key words: Rats; Cardiopulmonary bypass; Deep hypothermic circulatory arrest; Animal Model; lactate level; Organ damage

Application of high frequency color Doppler ultrasound combined with wide-field imaging in the preoperative navigation of anterolateral thigh perforator flap surgery

To investigate the application of high frequency color Doppler ultrasound (HFCDU) combined with wide-field imaging in the preoperative navigation of anterolateral thigh perforator flap graft. Between January 2017 and March 2018, 28 patients with skin and soft tissue defects were treated, including 22 males and 6 females, with an average age of 33.5 years (range, 17-66 years). The causes of injury included 2 cases of scald scar, 7 cases of heavy object crushing injury, 12 cases of traffic accident injury, 4 cases of fall injury, 2 cases of machine injury, and 1 case of infection ulcer. Injury sites included 6 cases of hand and wrist, 12 cases of lower leg, 10 cases of foot. After debridement, the wound area ranged from 6.0 cm×3.5 cm to 24.0 cm×9.0 cm, and all patients were treated with free circumflex femoral artery perforator flap graft. Combo of HFCDU and wide-field imaging navigation were done preoperatively to detect the origin, quantity, course, surface location, hemodynamic characteristics, and the relationship with body area of perforator branch of lateral circumflex femoral artery. According to the perforator information displayed by wide-field imaging of source artery, the dominant perforator was determined to be a pedicle for designed flap. The flap size ranged from 7.0 cm×4.5 cm to 26.0 cm×7.0 cm. The flap donor area was sutured directly. The dominant perforator was successfully detected by HFCDU combined with wide-field imaging in 28 patients before operation. The existence of the perforator was confirmed during operation, and the location was accurate. The course characteristics of the perforate were consistent with the results of wide-field imaging. The grafted flaps survived completely among 27 patients after operation. Necrosis at the edge of the flap was observed in 1 patient, which healed after dressing change. All patients were followed up 3-12 months, with an average of 9 months. All the flaps have good blood supply, good elasticity and shape. The donor areas healed perfectly. Using HFCDU and wide-field imaging navigation for designing of anterolateral thigh perforator flaps can clearly show the characteristics of perforators, hemodynamic information, and the relationship with body area, so that the surgeons can understand the perforators more accurately and intuitively, and improve the success and efficiency of flap graft surgery.

Application of a new classification of chimeric anterolateral thigh free flaps

BackgroundThe anterolateral thigh free flap is one of the most commonly used flaps in reconstructive procedures. The purpose of this study was to assess this new classification of chimeric anterolateral thigh free flaps. MethodsSixty-five patients underwent free anterolateral thigh chimeric free flap reconstruction of defects in the head and neck region. We summarized the anatomic features of perforators, including the number and origin of the perforators. ResultsSixty-five cases of femoral anterolateral double island flaps were divided into 3 types: trunk type (type I), 11 cases (16.9%), in which the perforators of two flaps originated in the descending branch and the transverse branch of the lateral femoral circumflex artery; branch type (type II), 45 cases (69.3%), in which both the perforators originated in the descending branch or the transverse branch of the lateral femoral circumflex artery; and bifurcation type (type III), 9 cases (13.8%), in which two perforators originated in the bifurcation of one perforator that originated in the descending branch or the transverse branch of the lateral femoral circumflex artery. All 65 flaps survived and none showed partial necrosis. ConclusionsThe anterolateral thigh chimeric flap can be divided into 3 types: trunk type (I type), branch type (II type) and bifurcation type (III type).

Neurologic recovery after deep hypothermic circulatory arrest in rats: A description of a long-term survival model without blood priming.

Brain injury associated with deep hypothermic circulatory arrest (DHCA) has been recognized in patients with congenital heart diseases and those undergoing aortic arch surgeries. However, the preclinical investigation of long-term cerebral injury and recovery mechanisms related to DHCA has been restricted to a satisfactory recovery animal model with a determined recovery time. This study aimed to evaluate the feasibility of a long-term surviving DHCA model without blood priming in rats, in order to investigate the pathophysiology of long-term complications in further studies. Twelve Sprague-Dawley rats were divided into 2 groups: sham group (n=3) and DHCA group (n=9). The DHCA group was further assigned to the surviving time of postoperative day 2, 14, and 30 (n=3, respectively). The entire cardiopulmonary bypass (CPB) circuit consisted of a modified reservoir, a custom-designed small-volume membrane oxygenator, a roller pump and a heater/cooler. A 24-G catheter was cannulated in the branch of the left femoral artery for arterial blood pressure monitoring. Cardiopulmonary bypass was established via the right external jugular vein-right atrium and tail artery. Rats were cooled to a rectal temperature of 18°C, followed by 30minutes of DHCA with global ischemia. After re-warming for approximately 40minutes, the animals were weaned from the CPB at 35.5°C. Blood gas and hemodynamic parameters were recorded preoperatively and intraoperatively, and at 2, 14, and 30 days postoperatively. Thereafter, the brains were perfusion fixed and histologically analyzed. All DHCA processes were successfully achieved, and none of the rats died. Blood gas analysis and hemodynamic parameters at each time point were normal, and vital signs of all rats were stable. Histopathologic deficits in the hippocampus (pathological score, surviving hippocampal neurons, and Ki67-positive neurons) manifested after 30 minutes of DHCA, which persisted for at least 14 days and recovered after 30 days. A novel and simple long-term recovery model of DHCA in rats was established in the present study, and histopathologic deficits were observed after clinically relevant 30-minute DHCA durations, in order to determine the 30-day recovery time frame.

Ligature of the deep medial femoral circumflex artery decreases the incidence of transfusion in primary total hip arthroplasty

Background: Primary total hip arthroplasty (THA) is associated with substantial blood loss during the surgical approach and the postoperative period. This causes a decrease in hemoglobin levels up to 5 g/dL, and blood transfusion rates that vary between 30% and 73%. The purpose of this study was to compare the rate of blood transfusions in patients with or without ligature of the deep branch of the medial femoral circumflex artery (MFCA) during THA. Methods: A randomized controlled trial of patients who underwent primary THA between January and October 2011 was conducted. Patients were randomly allocated to either ligature or no ligature of the deep branch of the MFCA. The number of units of red blood cells transfused and surgical time were defined as main outcomes. Differences between groups were assessed using Student’s t-test. Results: A total of 146 patients were analyzed. Artery ligation reduced the need for blood transfusion in 74% (P&lt;0.001) of patients and was identified as a protective factor in 76% of the sample. A mean decrease in bleeding of 200 cc (P&lt;0.001) and mean increase of 2 minutes (P=0.61) in surgical time were found in the ligature group. This difference in the total surgical time between the two groups was not significant. Discussion: Ligature of the deep branch of the MFCA decreases the need for blood transfusion without increasing the surgical time or the difficulty of the procedure. We recommend that surgeons include this step during a THA surgical approach.

Anatomical and radiological study of the variations of profound femoris artery and its branches

Introduction The femoral artery begins at the level of the midinguinal point as a continuation of the external iliac artery, and profound femoris artery (PFA) is the main branch of femoral artery that arises variably. Aim The aim of this study was to show the anatomical variations of PFA and its branches. Patients and methods (i) In the cadaveric study, femoral triangles of 20 lower limbs of 10 cadavers were dissected to study origin, course, and branches of PFA. The origin, course, and branches were noted. The distance of origin of PFA from midinguinal point was measured with the help of a scale. The width of femoral and PFA was measured with the help of a divider and a scale. (ii) In the radiological study, we retrospectively reviewed 49 patients (92 sides) undergoing femoral computed tomography angiography. Results Overall, 49.2% of them showed posterolateral origin of PFA on the right side and 62.7% on the left side followed by lateral origin in 33.9% on the right side and 23.7% on the left side, but the least percentage was to be posteromedial origin with no significant variations of other parameters (P≥0.05) except for medial circumflex femoral artery origin to lateral circumflex femoral artery origin site of origin between right and left sides (P≤0.05). Conclusion It could be concluded that variations of PFA and its branches are common, and it is most important to know variant origin of PFA and its branches, as they have an important role during preoperative clinical evaluation.

A numerical analysis of the effects of the lower-limb prosthetic socket on muscle atrophy of the residual limb

Muscle atrophy of the residual limb after lower-limb amputation is a disadvantage of amputees' rehabilitation. To investigate the biomechanics mechanism of muscle atrophy of the residual limb, we built a finite element model of a residual limb including muscle, skeletons and main vessels based on magnetic resonance images of a trans-femoral amputee, and studied the biomechanics effects of the socket of the lower-limb prosthesis on the soft tissue and vessels in the residual limb. It was found that the descending branch of the lateral femoral circumflex artery suffered the most serious constriction due to the extrusion, while that of the deep femoral artery was comparatively light. Besides, the degree of the constriction of the descending branch of the lateral femoral circumflex vein, femoral vein and deep femoral vein decreased in turn, and that of the great saphenous vein was serious. The stress-strain in the anterior femoral muscle group were highest, while the stress concentration of the inferior muscle group was observed at the end of the thighbone, and other biomechanical indicators at the inferior region were also high. This study validated that the extrusion of the socket on the vessels could cause muscle atrophy to some degree, and provided theoretical references for learning the mechanism of muscle atrophy in residual limb and its effective preventive measures.

Occipital Artery to Posterior Cerebral Artery Bypass Using Descending Branch of the Lateral Circumflex Femoral Artery Graft for Treatment of Fusiform, Unruptured Posterior Cerebral Artery Aneurysm: 3-Dimensional Operative Video.

Posterior cerebral artery (PCA) aneurysms can be technically challenging lesions due to the intricacy of perforating branches and the relationship to cranial nerves and the brainstem. Fusiform aneurysms of the perimesencephalic segment of the PCA are a rare finding which does not favor direct clip occlusion or reconstruction. In such cases, proximal parent vessel occlusion is an option for aneurysm treatment. Extracranial-intracranial (EC-IC) bypass can be used to revascularize beyond the lesion when considering proximal occlusion. Based on previous literature for occipital artery (OA) bypass and the time-consuming dissection required for OA harvest, an interposition graft was chosen. The descending branch of the lateral circumflex femoral artery (DLCFA) is a good alternative interposition graft with a diameter that is favorable for revascularizing smaller, more distal vessels.This 3-dimensional video presents the case of a 26-year-old female with severe headaches who was found to have unruptured, fusiform aneurysmal dilatations of the PCA. Given the patient's youth and the morphology of the aneurysms, an EC-IC bypass with proximal occlusion was recommended. The DLCFA was used as an interposition graft. The left OA was found to be a suitable donor. A subtemporal approach was used to access the PCA for proximal occlusion. An occipital interhemispheric approach was performed to isolate a suitable recipient segment of the ipsilateral PCA branch for microvascular end-to-side anastomosis. Postoperative catheter angiography showed significant thrombosis of the fusiform aneurysms and a patent EC-IC bypass. Postoperative magnetic resonance imaging showed no infarcts and the patient was discharged neurologically intact.The patient was consented for inclusion in a prospective institutional review board (IRB) approved database from which this IRB approved retrospective report was performed. The consent for intraoperative video and picture use was also obtained.Images in the video between 0:49 and 1:11, © University of Southern California Neurorestoration Center. Used with permission, all rights reserved.

Repair of the soft tissue defects combined dead space in lower extremities with the descending branch of lateral circumflex femoral artery chimeric perforator flap

Objective To investigate the feasibility and clinical effects of chimeric perforator flap based on the descending branch of lateral circumflex femoral artery(d-LCFA) for reconstructing the three-dimensional tissue defect in lower extremities. Methods From May, 2008 to June, 2017, 79 cases of soft tissue defects with dead space were repaired by using a d-LCFA chimeric perforator flap, in which 33 cases of car accident trauma, 12 cases of chronic tibial osteomyelitis, 10 cases of plowing machine injury, 9 cases of chronic calcaneal osteomyelitis, 6 cases of falling injury, 5 cases of crushing injury, 3 cases of spoke injury, and 1 case of suppurative knee arthritis. These patients were accompany with different degrees of infection and dead space after radical debridement. The dead cavity was filled by muscular flap, and perforator flap covered the superficial wound. Recording the flap’s appearance, color, texture, osteomyelitis recurrence and the patient’s knee extension at 1, 3, 6, 9 and 12 months followed-up. Results Seventy-five flaps survived without complications, and the donor sites were closed directly. All patients had no postoperative hematoma or secondary infection. Vascular crisis occurred in 2 days after the operation in 4 flaps, 1 flap had an arterial crisis on the second-postoperative-day, and the flap was necrotic after surgical exploration. The deep circumflex iliac artery chimeric perforator flap was used for repairing. Three flaps with venous crisis during 48 h after operation, in which 2 flaps survived eventually after surgical exploration, and another flap was necrosis and repaired by skin graft. The followed-up periods ranged from 3 months to 30 months(mean, 9.7 months). All flaps had satisfied with appearance and texture. There were no osteomyelitis recurrence and any ranges of motion limitations in the hip and knee joints of the operated leg. Conclusion The chimeric perforator flap with d-LCFA merely anastomosed 1 group vascular pedicle can make the dead space be filled and cover the superficial wound simultaneously. It is an ideal option for reconstructing the skin defect with dead space in lower extremity, which can improve the quality of restoration of recipient site and reduce the damage of donor site. Key words: Lateral circumflex femoral artery, descending branch; Chimeric flap; Perforator flap; Dead space; Lower limb; Microsurgical technique

Efficacy and Outcomes of Posterior Inferior Cerebellar Artery (PICA) Bypass for Proximal PICA and Vertebral Artery-PICA Aneurysms: A Case Series.

Nonsaccular vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms have high morbidity and mortality rates and are difficult to treat using standard microsurgical or endovascular techniques. Definitive revascularization can require clip trapping and/or vessel sacrifice, with PICA bypass. The published surgical experience with these approaches is limited. We herein review our recent surgical experience with PICA revascularization for complex PICA and VA/PICA aneurysms. To determine the efficacy and outcomes of PICA bypass for revascularization of nonsaccular PICA and VA/PICA aneurysms. Retrospective analysis of an institutional review board-approved, prospective database was performed to identify patients with PICA and VA/PICA aneurysms treated with PICA bypass at a single institution. Demographic information, aneurysm characteristics, temporary clip time, and neurological outcomes were recorded. Ten cases of PICA revascularization were performed for both ruptured (n=8) and unruptured (n=2) nonsaccular proximal PICA or VA/PICA aneurysms. Seven cases were performed without vessel grafts; 3 cases required harvest of the descending branch of the lateral femoral circumflex artery. Mean temporary clip time was 38 min (range 27-50 min). Good outcomes (Glasgow Outcomes Scale score of 5) were achieved in 70% (n=7) of patients at time of discharge; the remaining patients had a Glasgow Outcomes Scale of 3. Two bypass-related complications occurred in this series; a hematoma at the graft harvest site requiring evacuation, and severe bypass graft spasm requiring multiple endovascular treatments. PICA bypass can be a safe, effective, and highly customizable tool for the revascularization of patients with nonsaccular proximal PICA and VA/PICA aneurysms.

Descending Branch of the Lateral Circumflex Femoral Artery Graft for Posterior Inferior Cerebellar Artery Revascularization.

Posterior inferior cerebellar artery (PICA) revascularization can be achieved with relative ease when a contralateral PICA is present. However, without a contralateral PICA, identification of a suitable vessel alternative can be challenging due to a size mismatch. To propose the descending branch of the lateral circumflex femoral artery (DLCFA) to be an acceptable, if not preferred, arterial graft for PICA revascularization. Data from patients who underwent PICA revascularization with DLCFA grafts were obtained from an institutional review board-approved prospectively maintained database with informed consent from the patients. Three patients, all presenting with ruptured aneurysms, were treated with PICA revascularization using the DLCFA. All cases achieved bypass patency and no ischemic events occurred during the bypass procedures. Graft spasm occurred in 2 patients. Two patients that presented with neurological deficits achieved excellent neurological outcomes and 1 suffered an anterior spinal artery stroke during a repeat endovascular treatment 1 wk after revascularization. The DLCFA is favorable for PICA revascularization when a contralateral PICA is not a viable option.

Knee reconstruction using a distally based anterolateral thigh flap: an anatomical cadaveric study.

To study the vascular territory of the descending branch of the lateral circumflex femoral artery and its anastomosis around the knee and to identify the cutaneous perforator supply to the distally-based or reverse flow anterolateral thigh (dbALT) flap. In particular, the distance of the first perforator branch arising from the knee and above region, as well as the number of branches and position of each perforator, beneficial for effective flap design, are also examined. Fresh cadaveric lower limbs were dissected and the distance of the first perforator branch arising from the knee and above regions, which are vascular supplies for flaps, as well as the number of branches and position of each perforator are described. A total of 54 thigh cadavers had at least two cutaneous perforator branches above the knee 10cm from the superior border of the lateral patella. The mean (± standard deviation) of the first perforator distance was 2.57±0.93cm above the superior-lateral border of the patella. All perforating branches were 4±2cm, 93% were 10±2cm from the superior lateral border of patella, and 100% were at 20±3cm (mid-thigh length) which were the traditional anterolateral thigh flap. The dbALT flap technique resulted in constant and reliable references about perforator sites. Thus, this type of flap is a viable option in patients who present with soft tissue defects around the knee and upper third of the leg.

Huge Pseudoaneurysm of the Femoral Artery after Internal Fixation of Femoral Trochanteric Fracture

Pseudoaneurysm is one of the most serious complications of femoral trochanteric fracture surgery. Since the rupture of pseudoaneurysm may lead to death, early detection is important. We report the case of an 80-year-old male who developed pain in the proximal thigh and severe swelling after internal fixation of a femoral trochanteric fracture with a hip nail. Angiography revealed a pseudoaneurysm of a branch of the deep femoral artery near the interlocking screw. The vascular lesion was immediately treated by transcatheter embolization, and the vascular leakage was completely resolved with catheter embolization. After embolization, the patient's clinical state improved rapidly, and the laboratory values improved to normal after several weeks. The current case study reminds us that pseudoaneurysm can occur after intramedullary nail placement to treat a femoral trochanteric fracture.

The Boomerang Thigh Flap: Optimizing the Donor Site for an Extended Skin Island Flap.

The anterolateral region of the thigh is one of the most used donor areas for flaps. However, there are cases in which large defects require more than the conventional skin island provided by the anterolateral thigh flap (ALT). For an extended skin island flap, we developed a new boomerang thigh flap (BTF), in which a boomerang design includes perforators from multiple branches of the lateral circumflex femoral artery (LCFA), providing a single-pedicle, large, reproducible, and reliable flap. We report the anatomical study and the use of the new BTF in a clinical series. We dissected 20 flaps in fresh cadavers to determine the anatomical landmarks, vascular pedicle pattern, perforator distribution, and BTF flap dissection technique. After achieving a reproducible and reliable technique, with primary closure of the donor site based on the pinch test, the BTF was applied for microsurgical reconstructions in the head and neck, lower limb, and upper limb regions. The BTF corresponds to a 45° confluence of the ALT and the tensor fascia lata (TFL) elliptical skin islands. It includes the perforators from the transverse/ascending and the descending branches of the LCFA , which conjoined into a single arterial LCFA pedicle in 85% (17) of the cadaver dissections. All the venous branches drained into a single lateral circumflex femoral vein. ALT perforator distribution followed literature descriptions, while TFL perforators were mainly septocutaneous and projected into a virtual rectangle of 6 × 4 cm at the lateral margin of the TFL. Average BTF dimensions were 40 × 8.6 cm. For the clinical cases, flap dimensions and pedicle characteristics were equivalent to the anatomical findings. The BTF was separated into two skin islands in four cases and no major complications were reported. The BTF is a reliable, reproducible, and divisible flap that provides extended skin island for reconstruction of large defects.

Bypass to the Descending Branch of the Lateral Femoral Circumflex Artery for Limb Salvage in a High-risk Patient with Critical Limb Ischemia

Bypass to the Descending Branch of the Lateral Femoral Circumflex Artery for Limb Salvage in a High-risk Patient with Critical Limb Ischemia

A Description of the Vascular Anatomy of the Tensor Fascia Lata Perforator Flap Using Computed Tomography Angiography.

The perforator anatomy of the tensor fascia lata (TFL) flap has been studied using cadaver dissection; however, exact descriptions of location, size, and origin of perforator vessels using preoperative imaging modalities remain limited. The aims of this study are to describe TFL perforator anatomy using high-resolution computed tomography angiography (CTA) and to correlate these findings with landmarks for the anterolateral thigh flap to facilitate flap planning. We identified 33 patients who previously underwent bilateral lower extremity CTAs for preoperative planning of free-flap reconstruction. The images were retrospectively reviewed, and the TFL perforator number, size, type, location, and overall pedicle origin and length were recorded. Thirty-three patients and 59 thighs were included in the study. There was an average of 2.5 perforators per TFL. All perforators arose from the ascending branch of the lateral circumflex femoral artery with an average pedicle length of 8.3 cm (range, 6.0-11.2 cm). Sixty-six percent of perforators were septocutaneous and 34% were musculocutaneous. The average perforator size as measured on CTA was 3 mm. The average perforator location was 10.1 cm inferior and 8.5 cm lateral to the line drawn from the anterior superior iliac spine to the superolateral patella. To our knowledge, this is the first study to characterize the vascular anatomy of the TFL perforator flap using high-resolution CTA and correlate this with well-established landmarks used in the planning for other thigh-based flaps. We believe data will facilitate flap design and dissection; potentially shortening operating room times, limiting exploratory incisions used to confirm the presence of thigh based perforators, and improving overall outcomes for patients.

Direct anterior approach to the hip joint in the lateral decubitus position for joint replacement.

The direct anterior approach for total hip arthroplasty is associated withhigher complication rates and difficult femoral component positioning. Performing a modified technique in the lateral position allows secure component positioning. Primary hip replacement (including femoral neck fracture) and cup revision without bone deficiency. Destruction/deformities of proximal femur or acetabulum, bone deficiency or malignancy. Strict lateral decubitus position. Straight anterior incision of 10-12 cm, starting 2 cm lateral to the anterior superior iliac spine. Incision of the fascia over the tensor fascia lata muscle (TFL). Lateral retraction of the TFL. Incision of the fascia and medial retraction of rectus femoris. Ligation of the ascending branch of the lateral femoral circumflex artery. Detachment of the iliocapsularis muscle from the capsule in amedial direction. Anterior capsule excision. Femoral neck osteotomy and removal of the head. Reaming of the acetabulum; insertion the acetabular component. Exposure of the femur. Incision/excision of the capsule medial to the greater trochanter for easy anteriorization of the femur. Reaming and implantation of femoral component. Weight bearing on day one with crutches for 4weeks; deep vein thrombosis prophylaxis. In all, 138 patients (72women, 66men, mean age of 67years) were followed up over 2years. Overall complication rate was 3.6%: 3patients (2.2%) with gradeIII complications required additional intervention. Acetabular cup inclination: 35-50° in 88% of patients. Neutral femoral stem position observed in 99% of patients. Mean Harris hip score improved from 61preoperatively to 97after 2years. Patient satisfaction on avisual analogue scale improved from 3.7 to 9.5.

Multidisciplinary Approach in the Treatment of Malignant Bone Tumors

Abstract Introduction. There are two types of tumor lesions at bone level: primary tumors and bone metastasis. These lesions cause a decrease in the structural strength of the bone that may lead to fracture. The goal of the orthopedic treatment is to resect the tumor, alleviate symptomatology, and restore the function of the limb. The orthopedic treatment consists of two phases: tumor resection and limb reconstruction. Treatment of such lesions implies extensive preoperative investigations to determine the local and general extent of the tumor and procedures aimed to facilitate resection. Case presentation. We present the case of a 58-year-old male, diagnosed with clear cell renal carcinoma three years before and treated by nephrectomy. Two months after surgery, the patient started reporting moderate pain in the hip, which gradually intensified. He was first seen in Foişor Hospital in December 2018 when a pathologic bone fracture in the trochanteric region of the right femur was discovered at the radiologic exam. This was supposed to be a bone metastasis from the previously operated renal cell carcinoma. The MRI investigation showed the presence of a large, polylobed bone tumor with an inhomogeneous structure, sized 80/ 72/ 82 mm extending in the adjacent soft tissue. Bone scintigraphy of entire skeleton revealed no other lesions and abdominal MRI exam revealed neither the recurrence of the tumor or the presence of abdominal metastasis. Significant vascularization of the tumor, from branches of the deep femoral artery, was evidenced on the Angio Computer Tomography. Due to the known profuse bleeding of such lesions, an angiography with embolization was also performed. Embolization was done with PVA particles, with a lack of post-embolization load. The Angio Computer Tomography scan performed at three weeks after embolization showed a reduction in size of the tumor. In March 2018 patient underwent bone resection and reconstruction with a G.M.R.S. tumor prosthesis. Resection was performed in a complex team involving also two vascular surgeons. The pathology exam confirmed it was a renal cell carcinoma bone metastasis. Results. At one week after the surgical procedure, the operative wound was healing, the patient had no pain, and he was gradually regaining ambulation. Conclusion. Surgical treatment of such neoplastic pathology is difficult and involves a multidisciplinary approach consisting of disciplines such as oncology, orthopedics, vascular surgery, and pathology. It also implies a significant contribution from radiology and interventional radiology.

Effects of anteriolateral thigh perforator flap and fascia lata transplantation in combination with computed tomography angiography on repair of electrical burn wounds of head with skull exposure and necrosis

Objective: To explore the effects of anteriolateral thigh perforator flap and fascia lata transplantation in combination with computed tomography angiography (CTA) on repair of electrical burn wounds of head with skull exposure and necrosis. Methods: Seven patients with head electrical burns accompanied by skull exposure and necrosis were admitted to our burn center from March 2016 to December 2017. Head CTA was performed before the operation. The diameters of the facial artery and vein or the superficial temporal artery and vein were measured, and their locations were marked on the body surface. Preoperative CTA for flap donor sites in lower extremities were also performed to track the descending branch of the lateral circumflex femoral artery with the similar diameter as the recipient vessels on the head, and their locations were marked on the body surface. Routine wound debridement and skull drilling were performed successively. The size of the wounds after debridement ranged from 12 cm×8 cm to 20 cm×12 cm, and the areas of skull exposure ranged from 8 cm×6 cm to 15 cm×10 cm. Anteriolateral thigh perforator flaps with areas from 13 cm×9 cm to 21 cm×13 cm containing 5-10 cm long vascular pedicles were designed and dissected accordingly. The fascia lata under the flap with area from 5 cm×2 cm to 10 cm×3 cm was dissected according to the length of vascular pedicle. The fascia lata was transplanted to cover the exposed skull, and the anteriolateral thigh perforator flap was transplanted afterwards. The descending branch of the lateral circumflex femoral artery and its accompanying vein of the flap were anastomosed with superficial temporal artery and vein or facial artery and vein before the suture of flap. The flap donor sites were covered by intermediate split-thickness skin graft collected from contralateral thigh or abdomen. Results: The descending branch of the lateral circumflex femoral artery and its accompanying vein were anastomosed with superficial temporal artery and vein in six patients, while those with facial artery and vein in one patient. All the flaps survived after the operation, and no vascular crisis was observed. Wound healing was satisfactory. One patient was lost to follow up. Six patients were followed up for 6 to 10 months. The patients were bald in the head operation area with acceptable appearance. No psychiatric symptom such as headache or epileptic seizure was reported. The flap donor sites were normal in appearance. The muscle strength of the lower extremities all reached grade V. The sensation and movement of the lower extremities were normal. Conclusions: Anterolateral thigh perforator flap with fascia lata transplantation can effectively repair electrical burn wounds of head with skull exposure and necrosis. The fascia lata can be used to protect the vascular pedicle of flaps, which is beneficial to the survival of the flap. Preoperative head and lower extremities CTA can provide reference for intraoperative vascular exploration in donor site and recipient area, so as to shorten operation time.

Bilateral Anatomic Variation of Anterolateral Thigh Flap in the Same Individual.

Background:Anterolateral thigh flap has gained popularity for its use as a soft-tissue flap for reconstruction of regional and distal defects. There is discrepancy between the predominant skin vessels-musculocutaneous or septocutaneous. The purpose of this study was to demonstrate anatomic variation of bilateral anterolateral thigh flap vasculature in the same individual.Methods:We performed an observational retrospective case series study in 11 patients and an observational prospective study in 7 cadavers to confirm our findings.Results:We found bilateral anatomic variation in the main cutaneous branch of the descendent branch of the lateral circumflex femoral artery between both thighs in the same individual. In 72.2% of cases, we observed that the main cutaneous branch was septocutaneous in 1 thigh and musculocutaneous in the contralateral thigh; in 16.7%, the main cutaneous branches were musculocutaneous in both thighs, and in 11.1%, the main cutaneous branches were septocutaneous in both thighs.Conclusions:Significant anatomic variation exists between the right and the left cutaneous branches of deep circumflex femoral arteries. Hence, preoperative imaging by computed tomography angiography (CTA) aids in determination of the vascular anatomy of the descending branch of the lateral circumflex femoral artery and in selection of septocutaneous branches, thereby reducing operative time.