External Vascular Compression Research Articles

Personalization of Minimally-Invasive Aesthetic Procedures with the Use of Ultrasound Compared to Alternative Imaging Modalities

Ultrasonography is a well-tolerated procedure that aids in the targeted esthetic therapies of special cutaneous regions, as well as in the prevention (vascular mapping, identification of previous filler, and others) and management of potential complications (vascular occlusion, external vascular compression, product misplacement or migration, inflammatory reactions, and others). It has lately been promoted as the first-line imaging tool to address injectables. In this article, we aim to review the evolving role of ultrasonography in cosmetic filler procedures, from the fundamental ultrasound characterization of cosmetic fillers to the ultrasound-enhanced detection and management of cosmetic filler complications, including ultrasound’s role in hyaluronidase-guided injections for cosmetic filler dissolution. Furthermore, the paper explores the integral role played by ultrasound in enhancing the precision, efficacy, and safety of additional minimally invasive aesthetic techniques such as mesotherapy, radiofrequency, cryolipolysis, and polydioxanone procedures.

Open and Thoracoscopic Aortopexy for Airway Malacia in Children: 15 Year Single Centre Experience

ObjectivesThe objective was to report and analyse the characteristics and results of open aortopexy and thoracoscopic aortopexy for the treatment of airway malacia in a paediatric population. MethodsWe report a retrospective consecutive case series of paediatric patients undergoing aortopexy for the treatment of airway malacia at a quaternary referral centre between December 2006 and January 2021. Outcome measures included days to extubation, continued need for non-invasive ventilation, further intervention in the form of tracheostomy and death. Results169 patients underwent aortopexy: 147 had open procedures (135 via median/limited median sternotomy and 12 thoracotomy) and 22 thoracoscopic. Mean follow up was 8.46 yrs (range 1–20 yrs). Most common site of airway malacia was the trachea (n = 106, 62.7 %), and 48 (28.4 %) had additional involvement at the bronchi with tracheobronchomalacia (TBM). 15 (8.9 %) had bronchomalacia (BM) only. Incidence of bronchial disease was lower in the thoracoscopic than open group (13.6 % vs 40.82 %; p < 0.0001). Mean time to extubation was 1.45 days, 2.59 days, 5.23 days in tracheomalacia, TBM and BM groups, respectively (p = 0.0047). Mean time to extubation was 1.35 days, 2 days, 3.67 days, and 5 days in patients with external vascular compression, TOF/OA, primary airway malacia, and laryngeal reconstruction, respectively (p = 0.0002). There were 21 deaths across the cohort, and all were in the open group. 71.4 % (n = 15) had bronchial involvement of their airway malacia. ConclusionsOpen and thoracoscopic aortopexy are effective treatments for airway malacia in children. We have identified that involvement of the bronchi is a risk factor for adverse outcomes, and the optimum treatment for this patient cohort is still debatable. Level of EvidenceIV. Type of StudyRetrospective Study.

Endoscopic and Image Analysis of the Airway in Patients with Mucopolysaccharidosis Type IVA.

Mucopolysaccharidosis (MPS) is a hereditary disorder arising from lysosomal enzymes deficiency, with glycosaminoglycans (GAGs) storage in connective tissues and bones, which may compromise the airway. This retrospective study evaluated patients with MPS type IVA with airway obstruction detected via endoscopy and imaging modalities and the effects of surgical interventions based on symptoms. The data of 15 MPS type IVA patients (10 males, 5 females, mean age 17.8 years) were reviewed in detail. Fiberoptic bronchoscopy (FB) was used to distinguish adenotonsillar hypertrophy, prolapsed soft palate, secondary laryngomalacia, vocal cord granulation, cricoid thickness, tracheal stenosis, shape of tracheal lumen, nodular deposition, tracheal kinking, tracheomalacia with rigid tracheal wall, and bronchial collapse. Computed tomography (CT) helped to measure the deformed sternal angle, the cross-sectional area of the trachea, and its narrowest/widest ratio (NW ratio), while angiography with 3D reconstruction delineated tracheal torsion, kinking, or framework damage and external vascular compression of the trachea. The NW ratio correlated negatively with age (p < 0.01), showing that airway obstruction progressed gradually. Various types of airway surgery were performed to correct the respiratory dysfunction. MPS type IVA challenges the management of multifactorial airway obstruction. Preoperative airway evaluation with both FB and CT is strongly suggested to assess both intraluminal and extraluminal factors causing airway obstruction.

Failure to Thrive and Severe Malnutrition due to a Jest of Nature: Dysphagia Lusoria

Dysphagia Lusoria is a rare condition in which dysphagia results from external vascular compression of the esophagus. We describe a 69-year-old man with longstanding intermittent solid-food dysphagia with failure to thrive who was found to have an aberrant right subclavian artery resulting in dysphagia lusoria. This caused a mass effect upon the posterior esophagus resulting in dilatation of the mid and upper esophagus. A diagnosis of dysphia lusoria was made and surgery was consulted for surgical correction and total parental nutrition started. Definitive diagnosis of dysphagia lusoria involves imaging modalities such as barium esophagram or a CT/MRI. Upper endoscopy is often normal though a pulsatile extrinsic mass can sometimes be seen. There are no pathognomonic manometric findings. Given the rarity of the condition, a high index of suspicion is often required for diagnosis. Definitive management of patients with dysphagia lusoria often involves surgical correction of the anatomical aberrancy. In patients who decline to undergo surgical correction, have mild-moderate symptoms, or are poor surgical candidates, eating slower, chewing well, taking smaller bites, and taking PPIs could be effective therapy options.

External vascular compression by hyaluronic acid injected by vacuum device

Filling with hyaluronic acid using a pen that injects with vacuum pressure in the lips region became popular due to not using needles, but it presents risks like any minimally invasive procedure. We present a case of injection of hyaluronic acid with this device in the labial region, which resulted in a subocclusion of the inferior labial artery. It is known that the use of pressure can offer a lower precision than the methods already used classically. Therefore, it is important to warn about the risks of this device, which despite not using needles, presents the same risks of complications.

Aortopexy for the management of paediatric tracheomalacia - the Alder Hey experience.

Whilst aortopexy is an accepted and established procedure, there remains considerable heterogeneity within the literature, with inconsistencies in both the approach taken and the technique employed. Furthermore, limited data exist on both patient selection and long-term outcomes. This study aimed to report the experience of managing severe tracheomalacia by way of aortopexy in a large UK paediatric centre. A retrospective case note review was conducted. Mean follow up was five years. Twenty-five patients underwent aortopexy for severe tracheomalacia caused by external vascular compression. Acute life-threatening events precipitated investigation in 72 per cent of cases. Twenty-one patients initially presented to ENT services for investigation, which comprised upper airway endoscopy and imaging with computed tomography angiography. Post-operatively, the majority of patients demonstrated complete resolution of symptoms and were discharged from all associated services. Only four patients required a tracheostomy. Aortopexy offers an effective method of treating severe tracheomalacia due to vascular compression.

External Compression Versus Intravascular Injection: A Mechanistic Animal Model of Filler-Induced Tissue Ischemia.

Soft tissue ischemia is a devastating and unpredictable complication following dermal filler injection. Multiple mechanisms to explain this complication have been proposed, including vascular compression, vessel damage, and intraarterial filler emboli. To elucidate the mechanism of injury, the authors introduce a mouse model, imaged with optical microangiography and laser speckle contrast imaging technologies, to demonstrate in vivo microvascular response to soft tissue and intravascular filler injection. To determine the effect of external vascular compression on distal perfusion, the authors attempted to occlude vessels with subcutaneous hyaluronic acid gel (HAG) bolus injections into the pinna of hairless mice. The authors also performed suture ligation of a major vascular bundle. Following these interventions, laser speckle and optical microangiography were performed serially over 1 week follow up. To determine the effect of intravascular HAG injection, the authors devised and validated a novel method of cannulating the mouse external carotid artery for intraarterial access to the pinna vasculature. Using this model, the authors performed intraarterial HAG injections and completed optical microangiography and laser speckle contrast imaging. Despite large HAG bolus injections directly adjacent to vascular bundles, the authors were unable to induce compressive occlusion of the mouse pinna vessels. Vascular occlusion was successfully performed with suture ligation, but optical microangiography and laser speckle contrast imaging confirmed undisturbed distal capillary bed perfusion. With intravascular HAG injection, large segments of pinna showed distinct perfusion reduction along a vascular distribution when compared with preinjection images, most noticeably at the capillary level. The novel mouse pinna model combining intravascular access and in vivo microvascular perfusion imaging has furthered the understanding of the mechanism of filler-induced tissue ischemia. Distal capillary perfusion was maintained despite external vascular compression. Intraarterial HAG filler injection, however, resulted in large areas of capillary nonperfusion and is the most likely etiology for filler-induced tissue necrosis that is observed clinically.

Late-onset superior mesenteric artery syndrome four years following scoliosis surgery - a case report.

Background: Superior mesenteric artery (SMA) syndrome has been reported as an uncommon condition of external vascular compression of the SMA particularly after rapid weight loss, body casts, or after corrective surgery for spinal deformities, usually within the first few weeks after surgery. Methods: This is a retrospective report of a case of a non-verbal autistic female patient who started to develop SMA syndrome at the age of 16, 4 years after posterior spinal fusion surgery for scoliosis. She was treated conservatively by increasing oral caloric intake, which resulted in increased body weight and relief of symptoms. Results: Seen at 10 years’ follow up, the patient is doing well, and is functional within the limits of her suboptimal cognitive and verbal conditions. She maintains good trunk balance with solid spinal fusion and intact instrumentation at latest follow up. Conclusion: Spinal surgeons should maintain a high index of suspicion for diagnosis of SMA syndrome even years after scoliosis surgery, especially for patients with communication problems, like the case we present here. Appropriate conservative measures can succeed in relieving the symptoms, increasing body weight, and preventing complications including the risk of death.

Bronchial Artery Pseudoaneurysm as an Unsuspected Cause of Hemoptysis in a Pediatric Patient

Hemoptysis in the pediatric population may be caused by foreign body aspiration, cystic fibrosis, bronchiectasis, or infection. Vascular causes are uncommon. We present a rare cause of hemoptysis related to a bronchial artery pseudoaneurysm. We report the case of a child with a bronchial artery pseudoaneurysm causing hemoptysis and describe the clinical evaluation, treatment, and outcome. A 12-year-old girl presented to a tertiary children's hospital with a history of daily, intermittent, moderate-volume hemoptysis. Rigid bronchoscopy showed a fresh clot occluding the right bronchus intermedius. Computed tomography angiogram was concerning for mild external vascular compression of the right mainstem bronchus. A bronchial arteriogram showed a right mid-bronchial pseudoaneurysm, which was embolized without complication. On repeat bronchoscopy, thrombus was removed from the bronchus intermedius with no new active bleeding. The patient was discharged in stable condition and did not have any more episodes of hemoptysis. Additional medical work-up did not reveal another source of the patient's bleeding. Hemoptysis in the pediatric population can be inflammatory, infectious, or due to systemic disease. Although extremely rare, bronchial artery pseudoaneurysm should be considered in cases of moderate to severe intermittent hemoptysis without another identifiable cause. Bronchial angiography can be both diagnostic and therapeutic.

Severe Bronchomalacia Treated by Combination of Nuss Procedure and Aortopexy: An Unusual Therapy Combination

Aortopexy is the treatment of choice for clinically significant tracheobronchomalacia from external vascular compression. When a marked chest depression is present, aortopexy may be less effective. We report 2 patients with pectus excavatum and vascular compression of the trachea who, despite their young age, benefited from combined Nuss bar insertion and aortopexy.

Tracheobronchial obstruction in children: experience with endoscopic airway stenting

Background We reviewed our experience to determine the role of endoscopic airway stents in children with tracheobronchial obstruction. Methods Seventeen children (10 boys and 7 girls) aged 2 months to 16 years underwent tracheobronchial stenting. Etiology of the tracheobronchial obstruction included external vascular compression (n = 9); tracheobronchial anastomotic strictures after heart-lung/lung transplantation (n = 4); airway compression by malignant mediastinal mass (n = 2), and subglottic/high tracheal stenosis after prolonged intubation with a tracheostomy in situ (n = 2). Indications for airway stenting were failure to wean from ventilator after a mean of 82.5 days (range, 2 to 210) in 8 children; and dyspnea or stridor in the remaining 9 children. Results Ten children had a total of 24 uncovered self-expanding metal stents (either Magic Wallstent or Ultraflex Microvasive) and 7 children had silicone stents (2 straight, 3 Y and 2 T tube stents). At follow-up at 1 week to 72 months (median 21), only 8 of 17 (47%) children were alive but all the deaths were secondary to the underlying pathology and not related to tracheobronchial stenting. Six of 8 ventilator-dependent children were extubated after a mean of 5.3 days (range, 2 to 11) after airway stenting. For the 9 children stented for dyspnea, mean Medical Research Council dyspnea score decreased from 3.0 to 1.6 after stenting. Conclusions Tracheobronchial stenting in children is only rarely needed and often undertaken in dire circumstances. The procedure has led to significant symptomatic benefit in dyspneic children and has enabled ventilator-dependent children to be extubated. Medium-term outlook after stenting with self-expanding metal stents for vascular compression of the airway is encouraging. The long-term outcome remains uncertain, however, and is ultimately influenced by the underlying disease.

Bronchomalacia associated with pulmonary atresia, ventricular septal defect and major aortopulmonary collateral arteries, and chromosome 22q11.2 deletion.

Respiratory distress is one of the major complications in young infants with pulmonary atresia, ventricular septal defect and major aortopulmonary collateral arteries (PA-VSD-MAPCA); however, its aetiology remains obscure. We have previously reported an association of bronchomalacia with PA-VSD-MAPCA in patients with a hemizygous deletion of chromosome 22q11.2 (del.22q11). To clarify the clinical relevance of bronchomalacia in patients with PA-VSD-MAPCA and del.22q11, we reviewed the clinical and laboratory records of four patients with PA-VSD-MAPCA who had del.22q11 and bronchomalacia. External bronchial compression by anomalous patterning of the aorta and MAPCA was documented in three of the four patients, using combinatorial examination of angiocardiography, bronchography, fibreoptic bronchoscopy and magnetic resonance imaging. One of the four patients died suddenly of severe respiratory distress at 4 years of age, while the remaining three were inoperable for complete surgical repair. Our study indicates that bronchomalacia as a result of external vascular compression may be an aetiology of early-onset respiratory distress in some patients with PA-VSD-MAPCA and del.22q11, and can significantly affect the clinical outcome.

Aortopexy in severe tracheal instability: short-term and long-term outcome in 29 infants and children

Background. Tracheal instability is a hazardous situation after operation for esophageal atresia. In cases with life-threatening apneas, aortopexy is a therapeutic option. To assess efficacy, short-term and long-term outcome was analyzed retrospectively. Methods. Between 1985 and 2000, 29 patients (age, 1.5 months to 5.2 years) were operated on. A flaccid trachea after operation for esophageal atresia was the cause for life-threatening apneas in 27, and there was external vascular compression in 2 patients. The operative procedure consisted of ventropexy of the aortic arch to the sternum and ventral thoracic wall. Results. There was neither early nor late mortality. A reversible lesion of the phrenic nerve was observed in 2 patients, a pneumothorax in 3, and secondary wound healing in 1. In all but 1 patient symptoms improved markedly or disappeared within days or within the first 3 months postoperatively. An increased susceptibility to respiratory infections was observed in long-term follow-up. Conclusions. Aortopexy can be performed with no mortality and low morbidity. Aortopexy is effective to prevent further life-threatening apneas, but does not prevent an increased susceptibility to respiratory infections.

Endobronchial Stenting for Extrinsic Compression Caused by Pulsatile Pulmonary Artery in a 4-Week-Old Infant

Respiratory compromise secondary to external vascular compression may complicate the course of infants and neonates undergoing repair of congeni tal heart disease. Management of such complications usually involves prolonged ventilatory support and even additional high-risk surgical procedures. In recent years, endobronchial placement of self-expanding stents became a realistic treatment option, although there is controversy as to which of the many stents available today give the best results. We report the first successful endobronchial placement of a self-expanding stent in a 4-week-old infant. This conservative treatment for extrinsic airway compression led to the rapid extubation and recovery of the patient.