Dissection Of Vessels Research Articles

Endovascular and Hybrid Repair in Patients with Heritable Thoracic Aortic Disease

In individuals with heritable thoracic aortic disease (HTAD), endovascular repair for treatment of aortic aneurysm and dissection may be lifesaving, but is associated with increased risk of failure of endovascular repair and adverse outcomes. This study reports our experience with early and late outcomes of endovascular aortic and branch vessel repair in patients with HTAD. A retrospective case series was performed by chart review of individuals with HTAD followed at Washington University School of Medicine/Barnes-Jewish Hospital who underwent endovascular aortic and/or branch vessel repair. Clinical features, imaging characteristics, and short- and long-term outcomes were collected. Twenty-nine patients with HTAD (20 male; mean age 45±13years) underwent 37 endovascular procedures between 2006 and 2020 with mean follow up of 54±41months. Seven patients underwent two or more separate endovascular procedures. Each procedure was considered separate for data collection and analysis. Underlying conditions included Marfan syndrome (n=16 procedures), Loeys-Dietz syndrome (n=14 procedures), vascular Ehlers-Danlos syndrome (n=3 procedures), and nonsyndromic HTAD (n=4 procedures). Twenty patients (69%) had prior open surgical aortic repair. Indications for endovascular aortic repair (n=31) included urgent repairs of acute complications of aortic dissection (n=10) or aneurysm rupture (n=3), and elective aortic repair (n=18; 10 chronic dissections and eight chronic aneurysms). Six patients underwent elective endovascular repair of six branch vessel aneurysms or dissections. Six patients underwent hybrid open surgical and endovascular repair. Of the 37 procedures, 25 (68%) proximal landing zones were in the native aorta or branch vessel, 11 (30%) were in a surgical graft or elephant trunk and one was in a previously placed endograft. Thirty-six (97%) procedures were technically successful, and none required emergency surgical conversion. Two patients died: one from sepsis and one from presumed late pseudoaneurysm rupture, for a 5% per-procedure mortality rate. Two procedures were complicated by stroke and one patient developed paraparesis. Of the 31 aortic procedures, seven aortic endografts (23%) developed a stent-induced new entry (SINE) discovered with imaging at 20±15days post-procedure. Seven endografts (23%) developed a Type I endoleak and eight (26%) developed a Type II endoleak. No Type III endoleaks were seen. Within 30days, two endografts (of 37, 5%) required reintervention. After 30days, fifteen additional endografts (of 37, 41%) required reintervention. Two patients (of 6, 33%) who underwent hybrid repair required reintervention. This study is the largest single-center case series examining outcomes of HTAD patients following endovascular repair. Urgent and elective endovascular repairs in patients with HTAD can manage acute and chronic complications of aortic aneurysm and dissection with relatively low risk. However, risk of early and late endoleaks and SINE is high. Close post-procedural surveillance is required, and many individuals will require additional interventions. Hybrid repair shows promise and requires further investigation.

Management of Calcification: Rational and Technical Considerations for Intravascular Lithotripsy

Arterial calcification (AC) is a common complication among patients with peripheral arterial disease (PAD). AC presents various challenges to PAD treatment including an increased likelihood of vessel rupture and dissection, and by acting as a physical barrier to drug delivery by angioplasty balloons. Intravascular lithotripsy (IVL) is a novel intervention that specifically targets AC by emitting sonic pressure waves that introduce microfractures in target calcified lesions to increase arterial compliance. Preliminary data has demonstrated the safety and efficacy of IVL in PAD treatment. The present article provides a technical overview of S-IVL, as well as a case series of the treatment of AC in common iliac, common femoral, superficial femoral, aortoiliac, and peroneal arterial lesions. Each case resulted in marked improvement of luminal patency, exhibiting the efficacy IVL.

Maximizing Angioplasty Results in Peripheral Interventions

The field of Interventional Radiology is said to have begun in 1964, when Dotter successfully restored circulation to an 82-year-old woman's leg with critical limb ischemia and gangrene by percutaneously dilating a localized stenosis of the superficial femoral artery using a Teflon catheter. The dilation catheter was revolutionary in the inception of angioplasty, and progress evolved with the development of angioplasty balloons. As angioplasty became more widely utilized, the focus turned to improving its results. Several factors are important to consider with regards to maximizing angioplasty results in peripheral interventions. These factors include vessel size, lesion length, lesion location, and the anatomic vascular bed. Operators must make thoughtful decisions regarding balloon choice, diameter, length, inflation pressures, inflation time, and employ these devices with excellent technique to optimize outcomes. Complications from angioplasty include elastic recoil, vessel dissection, vessel rupture, distal embolization, and neointimal hyperplasia. The most widely recognized limitation of angioplasty is the longevity of treatment effect. In order to improve long-term outcomes, different specialty balloons have been developed to address lesions resistant to plain balloon angioplasty and combat neointimal hyperplasia to improve outcomes. Ultimately the goal is to maximize vessel patency for the longest duration possible, and many exciting new technologies are on the horizon.

Hemothorax Occurring After Central Venous Catheter Removal: A Case Report

Background: Central venous catheterizations are used frequently in critical care unit. The procedure is associated with various complications ranging from mechanical ones during insertion and the possibility of vessel laceration and dissection to infections, not to forget haemothorax and pneumothorax that may require chest tube insertion. However, some complications may also origin from its removal. Case Report: This is a case of a 72-year-old patient with multiple comorbidities admitted to the Intensive Care Unit (ICU) for respiratory distress. A central line was inserted because a peripheral line was hard to establish, and as a consequence of catheter removal, he had a massive right-sided hemothorax. Conclusion: Central venous line removal could cause fatal complications such as massive hemothorax that should be looked for. We emphasize monitoring of patients after catheter removal because the uncommon nature of this complication can lead to diagnosis delay and even misdiagnosis.

Simulation of Reconstructive Microsurgery in Soft Embalmed Cadavers: A Teaching Module for Plastic Surgery Residents.

Background Cadaveric dissection courses-comprising flap harvesting techniques, vessel dissections, flap transfers to the defect, and microvascular anastomosis-would help residents gain confidence and master these difficult major reconstructive microsurgery procedures. Formalin embalmed bodies lack natural softness and many other features of a live body. Many soft embalming techniques have evolved to mimic live tissue and Theil technique is the most popular one among them. We explored alternate soft embalming options and started using Genelyn. Materials and Methods Over a span of 2 years (2019-2021), we have conducted three flap dissection workshops using soft-embalmed cadavers. Six soft-embalmed and two formalin-embalmed cadavers were used. Total number of participants was 80. Results Feedback of experience from the third course participants in the form of grades (1-5) for different criteria was obtained and evaluated. Confidence in the dissection of the various flaps and microsurgery is noticeable in all the participants. Conclusion Based on our experience, we propose that flap dissection and microsurgery training on soft-embalmed cadavers be included as a teaching module in the plastic surgery postgraduate curriculum.

The video is comprised of patient history, tumor location, preoperative pulmonary bronchi and vessels’ reconstruction, detailed surgical procedure, the specimen with nearest margin and postoperative chest CT scan 2-year after surgery. Detailed surgical procedure includes the dissection of segmental vessels and bronchi compared with 3D-reconstruction, exposure of segmental plane and the management of segmental plane.

The video is comprised of patient history, tumor location, preoperative pulmonary bronchi and vessels’ reconstruction, detailed surgical procedure, the specimen with nearest margin and postoperative chest CT scan 2-year after surgery. Detailed surgical procedure includes the dissection of segmental vessels and bronchi compared with 3D-reconstruction, exposure of segmental plane and the management of segmental plane.

Quantifying Complications: An Analysis of Operative Time and Intraoperative Factors in Microsurgical Breast Reconstruction.

Analysis of operative flow has been shown to improve efficiency in breast microsurgery. Both complex decision-making skills and technical mastery are required to overcome intraoperative challenges encountered during microsurgical reconstruction. Effects of intraoperative complications on operative time have not yet been reported. A retrospective chart review of microsurgical breast reconstructions by three surgeons between 2013-2020 analyzed operative variables and duration. Intraoperative complications were determined from the operative report. Correlations between continuous variables were determined using Spearman correlation coefficients. Nonparametric testing was used when comparing operative duration between groups. Operative duration was analyzed for 547 autologous breast reconstruction cases; 210 reconstructions were unilateral and 337 were bilateral. Average operative duration was 471.2 SD 132.2 minutes overall (360.1 SD 100.5 minutes for unilateral cases and 530.5 SD 110.5 minutes for bilateral cases). Operative duration decreased with surgeon experience (r = -0.17, p< .001).Regarding intraoperative complications, difficult donor dissection was correlated with an average operative duration increase of 91.7 minutes (n = 43, 7.9%, p< .001), pedicle injury with an additional 67.7 minutes (n = 19, 3.5%, p = .02) and difficult recipient vessel dissection with an increase of 63.0 minutes (n = 35, 6.4%, p = .003). Complications with anastomosis also showed a statistically significant increase in operative duration, with arterial complications resulting in an increase of 104.3 minutes (n = 41, 7.5%, p< .001) and venous complications resulting in an increase in 78.8 minutes (n = 32, 5.8%, p< .001). Intraoperative thrombus resulted in an increase of 125.5 minutes (n = 20, 3.7%, p< .001), and requiring alternative venous outflow added an average of 193.7 minutes (n = 8, 1.5%, p< .001). Intraoperative complications in autologous breast reconstruction significantly increase operative time. The greatest increase in operative time is seen with intraoperative thrombosis or requiring alternative venous outflow. As these complications are rarely encountered in breast microsurgery, opportunities for simulation and case-based practice exist to improve efficiency.

Individualizing medical suspension after knockout in boxing-no two knockouts are the same

Professional boxing carries high risk of acute traumatic brain injuries (TBIs). Subdural hematoma is the most common neurological cause of boxing related mortality. Other acute TBIs in boxing include epidural hematoma, intracranial hematoma, cerebral contusions, dissection of large vessels of the neck and concussion. Concussion or mild TBI is common in a sport like boxing where every punch thrown at the head is thrown with the idea of winning by causing a knockout (KO) which is nothing but a concussive injury of the brain. After a KO, the boxer is typically given a medical suspension. The adequate duration of medical suspension after a KO has neither been determined nor standardized.

Individualizing medical suspension after knockout in boxing-no two knockouts are the same

Professional boxing carries high risk of acute traumatic brain injuries (TBIs). Subdural hematoma is the most common neurological cause of boxing related mortality. Other acute TBIs in boxing include epidural hematoma, intracranial hematoma, cerebral contusions, dissection of large vessels of the neck and concussion. Concussion or mild TBI is common in a sport like boxing where every punch thrown at the head is thrown with the idea of winning by causing a knockout (KO) which is nothing but a concussive injury of the brain. After a KO, the boxer is typically given a medical suspension. The adequate duration of medical suspension after a KO has neither been determined nor standardized.

Endovascular Treatment of Acute Ischemic Stroke Due to Isolated Proximal Posterior Artery Occlusion.

BackgroundAcute ischemic stroke (AIS) due to isolated proximal posterior cerebral artery (PPCA) occlusion is rare but associated with high morbidity and mortality rates. However, the optimal treatment strategy for patients with AIS caused by PPCA remains unclear. We discuss our single-center experience with endovascular treatment (EVT) in patients with PPCA.MethodsData from patients with AIS due to PPCA occlusion were retrospectively analyzed. We analyzed procedural details, the degree of reperfusion, functional outcomes, and complications. Functional outcomes were determined using the modified Rankin Scale (mRS) at 90 days, and good outcome was defined as mRS 0–2 at 90 days. Successful reperfusion was defined as modified treatment in cerebral ischemia (mTICI) 2b−3 after endovascular therapy. Safety variables included symptomatic hemorrhage (defined as an increase of four or more points in the National Institute of Health Stroke Scale score), vessel perforation or dissection, and new ischemic stroke in different territories.ResultsSeven patients were included in this study. The mean age of the patients was 64 ± 12.4 years. Successful reperfusion was achieved in all seven patients (100%). Good outcomes were achieved at 90 days in 2 patients (28.6%), and favorable outcomes were observed in five patients (71.4%). One patient underwent angioplasty as rescue therapy after three attempts. One patient died because of severe gastrointestinal bleeding 24 h after EVT, which was probably a complication of intravenous alteplase. One patient had an embolism in the basilar artery and achieved complete reperfusion after rescue thrombectomy. Another patient had a complication of vessel dissection in the PPCA and underwent stent implantation as rescue therapy. We observed no recurrence of ischemic stroke or any intracranial hemorrhage on non-contrast computed tomography 24 h after the procedure.ConclusionEVT may represent an alternative treatment strategy for patients with acute ischemic stroke caused by PPCA.

Метод макромікроскопічного препарування для встановлення фетальної анатомічної мінливості структур пахвової ділянки

The purpose of the study was to determine a more sophisticated method of the most rational sequence of actions of dissection of the fascia, muscles, vessels and nerves of the axillary cavity in human fetuses in order to obtain standard results suitable for comparison in the age aspect. Materials and methods. The study of fetal anatomy of the structures of the axillary area was performed on 25 preparations of 4-10-month human fetuses of 81.0-375.0 mm parietal-coccygeal length using macromicroscopic dissection. Results and discussion. The axillary area is characterized by age and individual anatomical variability of the muscles that form its walls, fascia and cellular spaces, as well as vascular and nervous formations that pass in it, which is a common cause of complications during surgery. To study the fetal anatomical variability of the components of the axillary area, the algorithm of anatomical dissection of fascia, muscles, lymph nodes, blood vessels and nerves of the axilla in the human fetus is of priority importance. Adherence to the sequence of actions during the anatomical dissection of the components of the axillary area provides not only high representativeness and scientific value of the results, but also the rational use of biological material. The delta-thoracic sulcus fossa and the beak-shoulder muscle can be used to determine the topography and projection of the vascular nerve trunks of the axillary area. The obtained data on the variant anatomy of the pectoralis major and anterior dentary muscles, as well as the widest back muscle are consistent with the studies of individual authors. The study of the structure and topography of fascia, muscles, lymph nodes, nerves, arteries and veins of the axillary fossa in human fetuses from a macroscopic point of view in modern anatomy remains relevant and promising because micro- and ultramicroscopic anatomy does not provide a comprehensive answer and does not fully reveal the versatility of fetal anatomical variability, in the study of which the algorithm of anatomical dissection of the constituent formations of the axillary area becomes a priority. Conclusion. The projected and tested method of dissection of fascial-muscular and vascular-nervous formations of the axillary area in human fetuses provides a standard for obtaining data on their typical, individual and age anatomical variability. The order of actions used during the dissection of the muscles that form the walls of the axilla, fascial-cellular formations, vessels and nerves, as well as axillary lymph nodes in human fetuses preserves the naturalness of the appearance and relationships between the structures of the object of study. Macromicroscopic preparation revealed fetal anatomical variability of muscles, arterial and venous vessels and axillary nerves

What is the clinical benefit of left main coronary artery treatment by percutaneous coronary intervention?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The treatment of choice of left main coronary artery (LMCA) disease has been subject to intense debate and investigation in the last decade. More recent studies showed benefit of percutaneous coronary intervention (PCI) in patients with less complex coronary anatomy. Although it is not the standard treatment, the use of this technique has been increasing. Objectives Characterize the patient population undergoing LMCA PCI and analyze its clinical benefit. Also, try to identify patient profiles according to the composite outcome (angor, heart failure symptoms (HF), myocardial infarction (MI) or death) in short and medium term (30 days (D) and 180D). Methods Observational and retrospective study of patients submitted to LMCA PCI, between 1 January 2019 and 31 December 2020. A descriptive analysis was carried out. Chi-Square test was used for categorical variables and the T-Student test for numerical variables, with a significance level of 95%. CHIAD algorithm was applied to identify patient profiles – composite outcome was the dependent variable (fixed 15 parent nodes and 5 children nodes). For statistical analysis, SPSS 24.0 was used. Results N120 patients, mean age of 70,4 years (standard deviation of 10.8), 76% were male. 81.7% had multivessel disease, with LMCA-anterior descendig artery injury being the most frequent (31.7%). The average LVEF was 49%. The complication rate was 15.8%, most vessel dissections. The most serious complications (cardio-respiratory arrest and cardiogenic shock) occurred in 0.8% of cases. The composite outcome occurred in 25,2% (30D) and 13,3% (180D), regardless of past medical history and number/type of vessels affected. The presence of angor was 9.9% (30D) and 1.3% (180D); HF symptoms in 13.5% (30D) and 4.8% (180D); MI in 2.7% (30D) and 1.2% (180D) and mortality in 2.7% (30D) and 2.4% (180D). In a logic of dependence and profiles, patients with LVEF [45-55%] (95.6%-p=0.003) who treated the lesions in first intention (AdHoc) (100%-p=0.009) presented fewer occurrences at 30D. Patients with occurrences at 30D (65.2%-p=0.001) or without PV of LVEF (66.7%-p = 0.016) and dyslipidemia (53.8%-p = 0.027) were those with most occurrences at 180D. Conclusion This analysis highlights the experience of the angiography laboratory. The majority of patients experienced evident clinical improvement and recovered in shortand medium term. The rate of serious events was low. The analysis suggests that the greatest benefit were found in the profile of patients with LVEF [45-55%] with an AdHoc approach.

What is the clinical benefit of coronary chronic total occlusions treatment by percutaneous coronary intervention?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Coronary chronic total occlusions (CTO) are relatively common findings in the context of coronary angiography. The indication for revascularization of this type of lesions remains controversial. The recommendations of international cardiology societies consider the treatment of CTO by percutaneous coronary intervention (PCI) in selected patients, but this technique is not yet widely used in this context. Objectives Characterize the patient population undergoing CTO PCI and analyze its clinical benefit. Also, try to identify patient profiles according to the composite outcome (angor, heart failure symptoms (HF), myocardial infarction (MI) or death) in short and medium term (30 days (D) and 180D). Methods Observational and retrospective study with descriptive and comparative analysis of patients submitted to CTO PCI, between 1 January 2019 and 31 December 2020. A descriptive analysis was carried out. Chi-Square test was used for categorical variables and the T-Student test for numerical variables, with a significance level of 95%. CHIAD algorithm was applied to identify patient profiles, whose dependent variable was the presence or absence of the composite outcome (fixed 15 parent nodes- 5 children nodes). For statistical analysis, SPSS 24.0 was used. Results N177 patients were identified, with a mean age of 65.4 years (standard deviation of 11.1), 51% were female. The most frequent location of CTO was the right coronary in 41.2%. The composite outcome occurred in 23% (30D) and 16% (180D) of patients, regardless of past medical history. Angor was present in 9.4% (30D) and 5.3% (180D); HF symptoms in 12.3% (30D) and 5.3% (180D); MI in 2% (180D) mortality in 1.8% (30D) and 4.7% (180D). The complication rate was 5.1%, mostly cardio-respiratory arrest (2.5%) and vessel dissection (1.7%). In a logic of dependence and profiles, patients with LVEF&amp;gt;36% (80.1%-p=0.017), without HF symptoms (82.9%-p=0.007) and non-smokers/ ex-smokers (87.6%-p=0.043), were those with the greatest benefit at 30D. Patients with a history of NSTEMI (24.5%-p=0.018) and CKD (37.5%-p=0.048) were those with most occurrences presented at 180D. Conclusion This analysis highlights the experience of the angiography laboratory. In this pool, the majority of patients experienced evident clinical improvement and recovered in short and medium term. The rate of serious events during and after the procedure was low. This analysis suggests that the greatest benefit were found in patients with LVEF&amp;gt;36%, who didn´t develop post-procedure HF symptoms and in non-smokers/ex-smokers.

V05-01 3D AUGMENTED REALITY-GUIDED ROBOTIC-ASSISTED KIDNEY TRANSPLANTATION: REVEALING THE CONCEALED

You have accessJournal of UrologyCME1 May 2022V05-01 3D AUGMENTED REALITY-GUIDED ROBOTIC-ASSISTED KIDNEY TRANSPLANTATION: REVEALING THE CONCEALED Alberto Piana, Gallioli Andrea, Pietro Diana, Angelo Territo, Josep Maria Gaya, Pavel Gavrilov, Óscar Rodriguez Faba, Jordi Huguet, Lluis Guirado, Carme Facundo, Riccardo Campi, Andrea Bellin, Daniele Amparore, Sergio Serni, Joan Palou, and Alberto Breda Alberto PianaAlberto Piana More articles by this author , Gallioli AndreaGallioli Andrea More articles by this author , Pietro DianaPietro Diana More articles by this author , Angelo TerritoAngelo Territo More articles by this author , Josep Maria GayaJosep Maria Gaya More articles by this author , Pavel GavrilovPavel Gavrilov More articles by this author , Óscar Rodriguez FabaÓscar Rodriguez Faba More articles by this author , Jordi HuguetJordi Huguet More articles by this author , Lluis GuiradoLluis Guirado More articles by this author , Carme FacundoCarme Facundo More articles by this author , Riccardo CampiRiccardo Campi More articles by this author , Andrea BellinAndrea Bellin More articles by this author , Daniele AmparoreDaniele Amparore More articles by this author , Sergio SerniSergio Serni More articles by this author , Joan PalouJoan Palou More articles by this author , and Alberto BredaAlberto Breda More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002579.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic-assisted kidney transplantation (RAKT) has long shown solid results as a minimally invasive alternative to the standard open approach (OKT) for living donor and promising results for deceased donor. However, RAKT is still limited in those cases where the recipient’s iliac vessels present atherosclerotic plaques, frequently found in elder patients and in those subjected to long-term hemodialysis. Unlike OKT, where the surgeon can palpate the arterial plaques, in minimally-invasive surgery the haptic feedback is missing making the vascular clamping and arteriotomy unsafe. To overcome this limitation, 3-Dimensional (3D) imaging virtual reconstruction was employed using the Augmented Reality (AR) to intraoperatively locate the plaques, driving the surgeon during the crucial steps of KT. METHODS: Our study was conducted according to IDEAL model for surgical innovation. 3D printed and virtual models were obtained from high-accuracy conventional CT scan imaging and superimposed on the vessels during RAKT using the Da Vinci console software. RESULTS: In the IDEAL phase 0, 3D virtual models were obtained from patients with artery plaques, printed and compared to the vascular anatomy of the patient during 2 OKTs by manual palpation. In phase 1, the 3D virtual models of patients without plaques were superimposed during a combined open-robotic KT and 2 RAKTs. Anatomical fidelity was assessed by measuring and comparing the virtual model to the real vessels. Then, we employed the 3D AR on a clinical case without plaques during the vascular clamping and arteriotomy phases to gain insight of anatomy modification during vessel dissection. The correspondence of 3D virtual models with the real anatomy of patients with plaques was tested by scanning the iliac arteries with a robotic ultrasound (US) probe in 10 patients undergoing robotic-assisted iliac lymph-node dissection for prostate cancer. Finally, after US confirmation, the 3D-AR accurately enabled the surgeon to place the clamp and perform the arteriotomy safely in a clinical case with arterial plaques. CONCLUSIONS: The employment of 3D-AR allowed to overcome one of the main limitations of RAKT, setting the foundation to expand its indications to patients with advanced atheromatic vascular disease. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e516 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alberto Piana More articles by this author Gallioli Andrea More articles by this author Pietro Diana More articles by this author Angelo Territo More articles by this author Josep Maria Gaya More articles by this author Pavel Gavrilov More articles by this author Óscar Rodriguez Faba More articles by this author Jordi Huguet More articles by this author Lluis Guirado More articles by this author Carme Facundo More articles by this author Riccardo Campi More articles by this author Andrea Bellin More articles by this author Daniele Amparore More articles by this author Sergio Serni More articles by this author Joan Palou More articles by this author Alberto Breda More articles by this author Expand All Advertisement PDF DownloadLoading ...

Incidence of Procedure-Related Complications in Patients Treated With Atherectomy in the Femoropopliteal and Tibial Vessels in the Vascular Quality Initiative

Purpose: To compare procedural complications in patients undergoing atherectomy plus angioplasty (A+A) and plain balloon angioplasty (POBA). Materials and Methods: Patients in the Vascular Quality Initiative (VQI) registry undergoing first-time peripheral vascular intervention (PVI) were included. Those undergoing aortoiliac or pedal interventions, primary stenting, or hybrid procedures were excluded. Patients were stratified by lesion location (femoropopliteal [FP] or tibial [TIB]). The primary outcomes were target vessel dissection, distal embolization, and provisional stent placement. Secondary outcomes included postoperative complications and the need for subsequent interventions. Results: 12 499 patients undergoing FP (49.6% A+A) and 6736 patients undergoing TIB (17.0% A+A) interventions were identified. In the FP group, A+A was associated with greater intraoperative target vessel dissection (4.5% vs 2.6%, p<0.001), distal embolization (1.5% vs 0.7%, p =0.001), and provisional stent placement (1.5% vs 0%, p<0.001); and greater postoperative target vessel dissection (4.2% vs 2.0%, p<0.001) and distal embolization (0.9% vs 0.4%, p=0.034). In the TIB group, A+A was associated with fewer intraoperative vessel dissection (0.8% vs 2.3%, p=0.011) but greater provisional stent placement (0.3% vs 0%, p<0.001). TIB A+A was also associated with higher rates of technical success (97.6% vs 95.1%, p<0.001). Conclusions: Atherectomy was associated with increased procedural-related complications in femoropopliteal, but not in tibial vessels. Future studies addressing lesion morphology, device design, and technique may help define its role in peripheral vascular interventions.

Impact of supra-aortic vessel dissection on the neurological outcome in surgery for acute type A aortic dissection.

We investigated whether supra-aortic vessel (SAV)s dissection is a risk factor for neurological dysfunction (ND) after surgical repair for type A acute aortic dissection (TAAAD). A retrospective review was done in 178 patients with TAAAD undergoing aortic repair between 2015 and 2019, comparing those with SAV dissection to those without it. Preoperatively, 93 patients (54.4%) had SAV dissection. Postoperatively, ND occurred in 26 patients (14.6%), 17 of whom (65.4%) already had been present with preoperative ND. Patients with SAV dissection were more likely to have postoperative ND than those without it (21.5% vs 7.7%; p = 0.02). The severity of preoperative dissection-related stenosis in common carotid artery significantly related to postoperative ND (right; p =0.0071, left; p < 0.0001). Multivariable analysis showed dissection-related stenosis of > 75% in brachiocepharic and left common carotid arteries, and thrombosed false lumen in common carotid arteries were independent risk factors for postoperative ND. However, SAV dissection was not related to new onset of ND. Dissection with stenosis of > 75% in SAVs were significantly decreased after aortic repair and even after ascending aorta/hemiarch replacement. In conclusion, ND after surgical repair for TAAAD is closely related to SAV dissection, especially to stenosis of > 75% and thrombosed false lumen in common carotid arteries. Aortic repair significantly decreased SAV dissection and severity of stenosis.

The Use of Segmental Bone Resection to Assist in a Tension-Free Cleft Palate Repair

The traditional two-flap palatoplasty technique described by Veau-Wardill-Kilner is a two-flap palatoplasty suggests a posterior pushback movement of flaps should require an intact pedicle. Even a proper dissection of greater palatine vessels is done, some sort of tension burdens on the flaps due to the traction of the pedicle is inevitable. In addition to that, the right-angled flexion of the pedicle at the posteromedial bony corner of foramina palatinum majus diminishes blood flow. Particularly, in wide clefts, tight approximation of flap compromises the wound healing and resulting fistulas. A segmental bone resection from posteromedial wall of foramen palatinum majus as an outfracturing fashion is performed to assist a tension-free cleft palate repair. The more release of the pedicle from its hole loosens the flaps. It provides an easy posteromedial transposition of tissues. This maintains also most push-back movement of flaps.

Internal Mammary Lymph Node Biopsy during Microsurgical Breast Reconstruction: A Prospective Study.

Accurate assessment of regional lymph node basins is critical for oncological management of breast cancer. The internal mammary lymph node (IMLN) basin directly drains the medial pole of the breast, but biopsy is not commonly performed. While the axillary sentinel lymph node sample remains the standard of care, the majority of patients who have been found to have a positive IMLN biopsy have simultaneously had negative axillary sentinel lymph nodes. This study prospectively examines routine IMLN biopsy during microsurgical breast reconstruction. An IRB-approved study of routine IMLN biopsies in 270 consecutive patients who underwent microsurgical breast reconstruction was performed from July 1, 2018, to June 1, 2021. Recorded data included unilateral or bilateral breast reconstruction, unilateral or bilateral IMLN sampling, patient demographics, disease stage, and pathologic findings of IMLN. The majority of patients, 240 of 270 patients (88.9%), had bilateral reconstruction. Overall, 5 out of 270 (1.9%) patients had positive IMLN; one of these patients had positive axillary sentinel lymph nodes. The IMLN biopsy results in two of the five patients affected the clinical course as they were upstaged and required chemoradiation. Direct visualization of the internal mammary lymph nodes during dissection of the recipient vessels for microsurgical breast reconstruction allows for convenient sampling, with minimal donor site morbidity and enhances the therapeutic management of patients in whom nodal involvement is present. As such, the authors recommend IMLN sampling.

A New CT Analysis of Abdominal Wall after DIEP Flap Harvesting.

The abdominal microsurgical flap based on the deep inferior epigastric artery perforator (DIEP) flap has become the most popular option worldwide for autologous breast reconstruction. Several authors have investigated the results of reconstructed breasts, but the literature lacks systematic reviews exploring the donor site of the abdominal wall. To fulfil our aims, a new diagnostic muscle imaging analysis was designed and implemented. This study focused on rectus abdominal muscle morphology and function in a single series of 12 consecutive patients analysed before and after breast reconstruction with a microsurgical DIEP flap. Patients were divided into two groups, namely, “ipsilateral reconstruction” and “contralateral reconstruction”, depending on the side of the flap harvest and breast reconstruction, then evaluated by computed tomography (CT) scans scheduled for tumor staging, and clinically examined by a physiatrist. Numerous alterations in muscle physiology were observed due to surgical dissection of perforator vessels, and rectus muscle distress without functional impairment was a common result. Postoperatively, patients undergoing “contralateral reconstruction” appeared to exhibit fewer rectus muscle alterations. Overall, only three patients were impacted by a long-term deterioration in their quality of life. On the basis of the newly developed and implemented diagnostic approach, we concluded that DIEP microsurgical breast reconstruction is a safe procedure without major complications at the donor site, even if long-term alterations of the rectus muscle are a common finding.

Acute Ischemic Stroke Due to Spontaneous Internal Carotid Artery Dissection in a Human Leukocyte Antigen (HLA) B27 Young Male

Carotid artery dissection is a significant cause of stroke in young patients. Here, we report a 33-year-old male who presented with right homonymous hemianopia and paresthesia of the right side of the body. Magnetic resonance imaging (MRI) of the brain revealed an acute infarct in the left parieto-occipital region. Magnetic resonance angiography (MRA) and duplex ultrasonography (USG) of the neck vessels suggested the left internal carotid artery dissection as the underlying cause. The patient was a known human leukocyte antigen (HLA) B27 and had a history of a previous attack of uveitis. This case report will raise awareness regarding the possible association of HLA B27 with the dissection of neck vessels.