Hand-held Doppler Research Articles

A Laser Atherectomy-Thrombectomy System for Primary Management of Acute Limb Ischemia.

To evaluate the primary use of a laser atherectomy-thrombectomy system in patients with acute limb ischemia (ALI). A single-center retrospective review of patients presenting with ALI (14 days or less) from August 2021 to February 2024 treated primarily with a laser atherectomy-thrombectomy system (Auryon; Angiodynamics, Queensbury, New York) was performed. Technical success was defined by resolution of the acute occlusion with adequate inflow and outflow with pedal signals detectable by handheld doppler ultrasound. Primary clinical endpoints were resolution of symptoms without readmission or reintervention in the immediate post-procedure period and at 30 days with follow-up duplex ultrasound documenting patency of the treated limb. 24 procedures in 21 patients were included (mean age 60 years, M:F 1:0.7). 75% of patients (18/24) presented as Rutherford 1, 12.5% Rutherford 2A (3/24), and 12.5% Rutherford 2B (3/24), with a mean symptom duration of 4 days. Technical success was 92% (22/24) in a single session. Two technical failures required overnight adjuvant thrombolysis. 100% of patients met the immediate post-procedure endpoint, and 92% met the 30-day endpoint. There were no major device-related adverse events or deaths within 30 days, with a major amputation rate of 5%. Distal embolization occurred in 7 (29%) of cases, most of which were focal tibial emboli occurring after adjunctive plain balloon clot maceration and resolved with balloon maceration and/or additional passes of the laser atherectomy-thrombectomy system. The use of a laser atherectomy-thrombectomy system is a feasible option as a primary treatment modality for ALI.

Nail reconstruction using an osteo-onychocutaneous flap with the dorsal digital artery of the hallux as the pedicle: Techniques and anatomical insights

Nail reconstruction with preserved pulp tissue can be challenging due to the use of oversized flaps and nail deformities often resulting from bone resorption. This study describes a novel technique using the dorsal digital artery of the hallux as a pedicle for an osteo-onychocutaneous flap. A preoperative handheld Doppler was used to identify the course of the dorsal digital artery, and intraoperatively, the flap was elevated without disturbing the plantar tissue, thereby minimizing the risk of foot complications. A prospective study was conducted on all partial toe transplantation cases between September 2020 and March 2023 to analyze the anatomical variations of the dorsal digital artery. Thirty-one patients were included in the study. The dorsal digital artery was successfully identified preoperatively and confirmed intraoperatively in all cases. It branched from the first dorsal metatarsal artery in 24 cases and from the plantar digital artery in seven cases. The branching location was found to be 24.3 ± 4.5mm proximal to the web in the former group and 3.9 ± 3.9mm (p < 0.001) in the latter group. The vascular diameter at the branching site was measured to be 0.8 ± 0.2mm, with no significant difference based on the location. Nail reconstruction procedures were successfully performed using this flap for defects in the thumb, index finger, and little finger. Stable nails were reconstructed in all cases with minimal foot complications. In conclusion, this technique offers a reliable approach to nail reconstruction, minimizing donor site morbidity and preserving natural nail morphology.

Computed tomographic angiography in planning thoraco-dorsal artery perforator flap in breast and soft tissue reconstruction: a systematic review.

Thoraco-dorsal artery perforator (TDAP) flaps have been increasingly used in breast and soft tissue reconstruction. Perforator localization is often done using a hand-held doppler, however, false results are not uncommon. This study aimed to systematically review the literature on the value of preoperative computed tomographic angiography (CTA) in TDAP flaps examining scanning protocol, mapping technique, concordance with operative findings, and disadvantages. A PRISMA-compliant comprehensive search of Medline, Embase, Cochrane Library, and CINAHL databases was conducted in November 2023. We included studies evaluating CTA mapping of free and pedicled TDAPs for breast or soft tissue reconstruction using The Joanna Briggs Institute (JBI) Critical Appraisal Tools. Five studies were included and considered at high risk of bias. The studies included 72 patients with a mean age of 43.8 years. Concordance between CT findings and Doppler mapping or operative visualization was reported in two studies. In three studies, CTA was combined with Doppler flowmetry, whilst dynamic infrared thermography was used in one study. Standardized scanning protocol and patient positioning were lacking in all reports. This study highlights the paucity of evidence on the value of CTA in TDA perforator mapping with inconsistent outcomes and non-standardized scanning protocols. Despite difficult imaging acquisition and interpretation, 3D reconstructed images and detailed vascular anatomy may facilitate planning. Further research is required to explore the practical value of CTA in TDAP planning and standardizing protocols.

Analytical HPLC Method for Determination of Miconazole Nitrate and Eugenol in Formulated Emulgel

A diabetic foot ulcer (DFU) is the prime cause of poor quality of life among diabetic patients. DFU leads to physical disability and an enormous economic burden on diabetic patients. The development and prognosis of DFU are preventable in most patients by modifying the risk factors for DFU. Programs intervened by clinical pharmacists can enhance rational drugs use and improve the early identification and prevention of DFU. This study intended to prove the beneficial outcome in identifying the risk factors and the provision of patient-tailored referral advice regarding DFU among diabetic patients. This cross-sectional study assessed the neuropathy through Michigan Neuropathy Screening Instrument (MNSI), Monofilament and Vibration test using Tuning Fork and Handheld Doppler for assessing the lower limb vascular disease as per NICE guideline among 137 diabetic patients. 64% of patients were found to have symptoms of neuropathy through the neuropathy assessment test whereas 36% did not have the symptoms. Foot sensory using monofilament test was found to be normal in 49.64% of DFU patients, reduced in 43.80%, and absent in 6.57% of DFU patients. The Ankle Brachial Index (ABI) was found to be normal in 48% of patients, mild in 34% of patients, moderate in 12% of patients, and incompressible in 6% of patients. Clinical Pharmacist intervened risk assessment through Hand-held Doppler, MNSI instrument, and Vibration test helped in screening the DFU patients for Neuropathy, and implementation of effective per patient-tailored education was found to be beneficial in the early identification of DFU and referral to specialty hospitals

How well can the fetal heart rate baseline be assessed by intrapartum intermittent auscultation? An interrater reliability and agreement study.

We aimed to examine the inter-reliability and agreement among midwives when assessing the fetal heart rate (FHR) using the handheld Doppler. The primary aim was to measure the reliability and agreement of FHR baseline (baseline) as beats per minute (bpm). The secondary aims were to measure fluctuations from the baseline, defined as increases and decreases, and classifications (normal or abnormal) of FHR soundtracks. This is the first interrater reliability and agreement study on intermittent auscultation (IA) to our knowledge. The participant population consisted of 154 women in labor, from a mixed-risk population and admitted to hospital for intrapartum care. The rater population were 16 midwives from various maternity care settings in Norway. A total of 154 soundtracks were recorded with a handheld Doppler device, and the 16 raters assessed 1-min soundtracks once, through an online survey (Nettskjema). They assessed the baseline, FHR increase or decrease, and the FHR classification. The primary outcome, baseline, was measured with intraclass correlation coefficient (ICC). The secondary outcomes were measured with kappa and proportion of agreement. The interrater reliability for the baseline (bpm) was ICC(A,1) 0.74 (95% CI 0.69-0.78). On average, an absolute difference of 7.9 bpm (95% CI 7.3-8.5 bpm) was observed between pairs of raters. Our results demonstrate an acceptable level of reliability and agreement in assessing the baseline using a handheld Doppler.

Correlation of ankle-wrist pressure index with ankle-brachial pressure index to assess lower limb perfusion in diabetic foot ulcer: a pilot study.

The presence of peripheral artery disease (PAD) in patients with diabetic foot ulcers (DFUs) is a significant risk factor for chronicity and amputation. Ankle-brachial pressure index (ABPI) is a screening tool for PAD. Brachial systolic pressure measurement, used as a denominator in the calculation of ABPI, produces inaccurate results in patients with obesity and the presence of heavy clothing. The wrist, however, is easily accessible, and the ankle-wrist pressure index (AWPI), if comparable with ABPI, may be useful in screening selected patients. This study aimed to assess the efficacy of AWPI in diagnosing perfusion in DFUs and compare it to ABPI in patients with DFUs. ABPI and AWPI were calculated by measuring systolic blood pressure in the arteries of the ankle, arm and wrist with a handheld Doppler. Actual perfusion was determined by the presence or absence of PAD by duplex ultrasound. A total of 46 lower extremities in 41 patients were studied. The prevalence of PAD was 61%. Duplex ultrasound confirmed that the sensitivity of ABPI and AWPI in detecting PAD in patients with DFUs was 67.9% and 71.4% respectively, whereas the specificity of ABPI and AWPI was 94.4% and 88.9% respectively. On receiver operating characteristic analysis, the area under the curve of ABPI and AWPI was 0.804 and 0.795, respectively. A statistically significant positive correlation between ABPI and AWPI was found (r=0.986; p<0.001). There was a good correlation between ABPI and AWPI over a wide range of values. ABPI and AWPI may have a similar role in predicting perfusion in patients with DFUs. AWPI could be used in place of ABPI in selected patients in whom measuring ABPI may be difficult. The authors have no conflicts of interest to declare.

Projected augmented reality in DIEP flap breast reconstruction: Projecting perforators on the skin using dynamic infrared thermography

BackgroundDynamic infrared thermography (DIRT) is a quick and non-invasive technique for perforator mapping in free flaps that provides real-time information. After a cold challenge, areas best supplied with blood become visible hotspots on color-coded maps, indicating perforators. This study presents a proof of principle for a new and innovative feature of DIRT, where projected augmented reality is used to directly display thermal images on the patient’s abdomen prior to the deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. MethodsA self-aligning projection device prototype (Anatomy Projector) equipped with an integrated thermal camera was used to obtain thermal information and project the color-coded map directly on the patient’s abdomen before DIEP flap breast reconstruction. Projected DIRT hotspots were verified using a hand-held Doppler, and compared to the vascularity on computed tomography angiography (CTA), and intraoperative perforator measurements following a Cartesian grid. ResultsA total of 514 DIRT hotspots were projected in 50 patients, among them 97.3% could be verified using Doppler. The positive predictive value for CTA was 74.5%. Intraoperative measurements yielded 132 perforators in 71 flaps, among them 75 perforators (56.8%) correlated with projected DIRT hotspots, and half of them (54.7%) appeared within the first 5 emerging hotspots. ConclusionThis study showed that real-time display of thermal data in DIEP flap breast reconstruction is feasible via projected augmented reality. Projection facilitates convenient marking of hotspots, and a high resemblance to Doppler and CTA data was observed. Further research should assess the added value of projecting thermal images intraoperatively and in other fields of plastic surgery.

The effect of the different waves of COVID-19 pandemic on the outcome of diabetic foot ulcers.

COVID-19 pandemic has massively impacted human health. We studied the effect of COVID-19 on outcome of Diabetic foot ulcers (DFUs). We recruited 483 people with DFUs from June 2020 to April 2022 (pandemic) together with a matched group of 226 people with DFU from March 2019 to March 2020 (pre-pandemic). Primary endpoint was outcome of ulcers-healed or amputation (major/minor). It was sub-analysed into 3 waves of COVID-19. Secondary endpoint was healing of individual types of DFUs. Basic anthropometric data included site and type of ulcer (ischemic or neuropathic), duration, presence or absence of infection and Wagner's grading of DFUs was collected for all patients. Diagnosis of peripheral neuropathy was done by monofilament testing and peripheral arterial disease by handheld Doppler and ankle brachial index (ABI). Standardized treatment protocol was provided. All patients were monitored for 6 months. In the pandemic group 323 (66.9%) patients in whom ulcers healed, 70 (14.5%) underwent minor amputation, 11 (2.2%) major amputation, 29 (6%) were lost to follow up, 22 (4.6%) were not healed. Rate of healing of DFU was higher (66.9% vs 53.5%) and rate of amputation was lower (16.7% vs 23.4%) in the pandemic group than in the pre-pandemic group (P = 0.001 and 0.037 respectively). Rate of healing in first, second and third wave was 65.4%, 75.2%, 58.3% respectively (P = 0.001). Neuropathic ulcers though less prevalent (49.8% vs 57.8%) in the first two waves than in the third wave, healing was better (79.3% vs 75.6%) in the first two waves than in the third wave (P = 0.085 and 0.488 respectively). Similarly, amputation rates in ischemic and neuro-ischemic ulcers were greater in the third wave than first two waves (46.7% vs 15.7%, P = 0.049). During the COVID-19 pandemic, healing of neuropathic ulcers was better, especially in the first and second waves and travel restriction may have accounted for this. However, worsening of ischemic and neuro-ischemic ulcers was observed with more amputation in these two groups. Conversely, in the third wave withdrawal of lockdown led to worsening of DFUs resulting in less healing and more amputation.

A Practical Approach for Ischemic Preconditioning Intervention in Sports: A Pilot Study for Cuff Thigh Occlusion Pressure Estimation Based on Systolic Blood Pressure.

For the ischemic preconditioning (IPC) intervention, the accuracy of the protocol is paramount for mediating its possible ergogenic effects. However, the lack of standardization and widespread use of arbitrary cuff pressures (ranging from 130 to >300 mmHg) have been predominantly observed, potentially affecting the results and compromising the reproducibility of findings. Thus, the purpose of this study was to determine an appropriate cuff pressure during IPC. Seventeen healthy male participants were enrolled in the study. Anthropometric measurements were initially conducted, followed by systolic and diastolic blood pressure measurements. Subsequently, we determined the individual thigh occlusion pressure (TOP) for the right leg using a hand-held Doppler device. Based on these findings, we developed an estimation equation for TOP, considering the current brachial systolic blood pressure (SBP) values. We then conducted a retrospective analysis of its capacity to mediate occlusion. We observed the ability to estimate TOP using the equation (p = 0.01; ES: 0.86), presenting ~6% superiority in absolute values for occlusion compared to direct measurement (TOP equation: 169.9 ± 9.1; TOP direct measured: 161.2 ± 11.1). However, TOP estimation was insufficient to produce complete occlusion in two out of 17 subjects (11.8%). In conclusion, the estimation of TOP incorporating SBP values may offer a valid and practical means for cuff administration during IPC protocols with potential to minimize adverse effects and maximize its positive effects.

Reliability of systolic blood pressure measured by parents in young children at home using a hand held Doppler device and aneroid sphygmomanometer: methodological issue to avoid misinterpretation.

Reliability of systolic blood pressure measured by parents in young children at home using a hand held Doppler device and aneroid sphygmomanometer: methodological issue to avoid misinterpretation.

Propeller Flap: A Feasible Flap for Distal Third of Leg Defects – Two Cases Done at the Plastic Surgery Unit of the Greater Accra Regional Hospital

Introduction: The traditional way of reconstructing soft tissue defects of the lower limb utilized muscle flaps as the ‘gold standard’ for Gustillo Anderson Grade III B fractures of the upper and middle thirds of the leg. Defects of the lower third of the leg are usually reconstructed with free flaps because of paucity and decreased reach of muscles. In resource constrained environments where free flaps are not routine with high failure rates, fasciocuataneous flaps are the only option left. We present our experience with the novel pedicled propeller perforator flaps for reconstruction of soft tissue defects in the lower limb. Case Presentation: Between June and October 2020, 2 consecutive patients - a 34-year-old male and a 51-year-old female, were referred for cover for their distal leg defects from the Orthopedics and trauma Unit. All patients were operated on under spinal anaesthesia. Perforators from posterior tibial and peroneal arteries respectively, were identified pre-operatively with hand-held doppler and the propeller-pattern skin paddle was designed around the perforator closest to defect. After elevation of flaps and skeletonization of perforators, they were then rotated (180 degrees) and inset into defects. Case 1 had whole flap (104 cm2) surviving with only minor marginal epidemiolysis at tip whilst the second flap (58.5cm2) had necrosis of only the business end of the flap but subsequently healed by secondary intention after serial dressings. Both had secondary defects proximally after the rotation, which were skin grafted with 100% take. Conclusion: Propeller flap in our experience, is a feasible versatile option for reconstruction of soft tissue defects in the distal third of the leg.

(037) Trans Obturator Repositioning Sling (TOROS); Novel Proximal Fixation of Penile Prosthesis Cylinder in Neophallus

Abstract Introduction The placement of Penile Prosthesis (PP) in transgender men with a neophallus is technically demanding and poses challenges specifically related to the extracorporal proximal anchoring of the cylinders owing to the lack of proximal corpora. We herein designed a novel Trans-Obtutrator Repositioning Sling (TOROS) for the proximal PP cylinder anchoring in a phallus of cisgender man or a neophallus of transgender man. Objective To assess the safety and efficacy of this novel surgical approach for the extracorporal proximal PP cylinder anchoring (TOROS) in two patients (cisgender and transgender) through refashioned use of the AdVanceTM Male Sling System (Boston Scientific). We herein present one video (first patient) to demonstrate step by step surgical technique. Methods Two patients were included. First patient is a 38-year-old cisgender male with a history of micropenis who underwent anterolateral thigh phalloplasty in 2017 presents for PP insertion. Second patient is 35 year old transgender with history of right free flap forearm phalloplasty 2019 with prior failed PP revision presents with perineal pain at level of proximal PP cylinder. Both patients consented and elected to proceed. Results After careful identification of neophallus vascular pedicle with handheld doppler, a perineal midline incision was made. The space within the neophallus was carefully dissected, dilated up to 11mm with Hegar dilator and measured for upcoming PP cylinder. Next and similar AdVance Male Sling surgical approach, the Adductor Longus tendon identified as a landmark, a trocar was inserted carefully through the obturator foramen around the inferior ischiopubic ramus. The sling was pulled via perineal incision and refashioned into socket-like sling to house the proximal end of PP cylinder or Rear Tip Extender (RTE) (in this case). To further reinforce this connection, sling flanges wrapped around and suture fixated. Next a single-cylinder Ambicor PP (Boston Sci) is inserted. PP pump placed into the left perineal side. Total PP length was 15cm+2cm RTE. PP appeared cycling well. Skin closed in layers. Patient had an uneventful post-op course and discharged on POD #3. At the 6-week mark, the patient had no post-op complaints or complications. The patient has been able to cycle the penile implant twice daily without issue and satisfied with the outcome of the procedure. Conclusions Extra-corporal anchoring of PP cylinders using TOROS is a novel, feasible and potentially changing approach in cisgender or transgender men. Proximal anchoring of the cylinders on the inferior pubic ramus and ramus of the ischium through the modified and refashioned use of trans-obturator male sling mimic natural anatomical attachment of the proximal corpora, and the same approach can applied in a transgender man neophallus with apparent good stability with and without axial loading. Disclosure No.

Mapping of Thoracodorsal Artery Perforators: Accuracy of Thermography and Handheld Doppler.

The versatile musculocutaneous latissimus dorsi flap and the thoracodorsal artery (TDA) perforator flap have developed into indispensable approaches in reconstructive surgery. While the anatomy of the TDA is consistent, the skin perforators vary in location and course. Dynamic infrared thermography (DIRT) recently gained popularity for perforator identification; however, its use and accuracy in thoracodorsal artery perforator (TDAP) mapping is yet to be determined. TDAPs were visualized in 50 cases by DIRT. Based on the thermographic hotspots, the corresponding perforators were then identified by color duplex ultrasound (CDU) and handheld Doppler in a blinded fashion by two separate examiners. The midpoint of all perforator fascia passages was localized 99.7 mm caudal and 13.5 mm medial of the posterior axillary fold. The positive predictive value of perforator identification by dynamic infrared thermography was 86.5% and the correlating perforator fascia passage was 9.9 ± 5.8 mm from the hotspot midpoint, with a maximum of 29 mm. The positive predictive value of perforator identification by handheld Doppler was 95% and the signal was 7.2 ± 5.1 mm from the perforator fascia passage. DIRT precisely localizes TDAPs. The fusion with CDU combines both modalities' advantages. The combination with handheld Doppler is a fast way of perforator imaging, decreasing the handheld Dopplers' high false positive rate.

Monitoring of Women with Anti-Ro/SSA and Anti-La/SSB Antibodies in Germany-Status Quo and Intensified Monitoring Concepts.

Background: The fetuses of pregnant women affected by anti-Ro/anti-La antibodies are at risk of developing complete atrioventricular heart block (CAVB) and other potentially life-threatening cardiac affections. CAVB can develop in less than 24 h. Treatment with anti-inflammatory drugs and immunoglobulins (IVIG) can restore the normal rhythm if applied in the transition period. Routine weekly echocardiography, as often recommended, will rarely detect emergent AVB. The surveillance of these pregnancies is controversial. Home-monitoring using a hand-held Doppler is a promising new approach. Methods: To obtain an overview of the current practice in Germany, we developed a web-based survey sent by the DEGUM (German Society of Ultrasound in Medicine) to ultrasound specialists. With the intention to evaluate practicability of home-monitoring, we instructed at-risk pregnant women to use a hand-held Doppler in the vulnerable period between 18 and 26 weeks at our university center. Results: There are trends but no clear consensus on surveillance, prophylaxis, and treatment of anti-Ro/La positive pregnant between specialists in Germany. Currently most experts do not offer home-monitoring but have a positive attitude towards its prospective use. Intensified fetal monitoring using a hand-held Doppler is feasible for pregnant women at risk and does not lead to frequent and unnecessary contact with the center. Conclusion: Evidence-based guidelines are needed to optimize the care of anti-Ro/La-positive pregnant women. Individual risk stratification could help pregnancy care of women at risk and is welcmed by most experts. Hand-held doppler monitoring is accepted by patients and prenatal medicine specialists as an option for intensified monitoring and can be included in an algorithm for surveillance.

(185) Trans Obturator Repositioning Sling (TOROS); Novel Proximal Fixation of Penile Prosthesis Cylinder in Neophallus

Abstract Introduction The placement of Penile Prosthesis (PP) in transgender men with a neophallus is technically demanding and poses challenges specifically related to the extracorporal proximal anchoring of the cylinders owing to the lack of proximal corpora. We herein designed a novel Trans-Obtutrator Repositioning Sling (TOROS) for the proximal PP cylinder anchoring in a phallus of cisgender man or a neophallus of transgender man. Objective To assess the safety and efficacy of this novel surgical approach for the extracorporal proximal PP cylinder anchoring (TOROS) in two patients (cisgender and transgender) through refashioned use of the AdVanceTM Male Sling System (Boston Scientific). We herein present one video (first patient) to demonstrate step by step surgical technique. Methods Two patients were included. First patient is a 38-year-old cisgender male with a history of micropenis who underwent anterolateral thigh phalloplasty in 2017 presents for PP insertion. Second patient is 35 year old transgender with history of right free flap forearm phalloplasty 2019 with prior failed PP revision presents with perineal pain at level of proximal PP cylinder. Both patients consented and elected to proceed. Results After careful identification of neophallus vascular pedicle with handheld doppler, a perineal midline incision was made. The space within the neophallus was carefully dissected, dilated up to 11mm with Hegar dilator and measured for upcoming PP cylinder. Next and similar AdVance Male Sling surgical approach, the Adductor Longus tendon identified as a landmark, a trocar was inserted carefully through the obturator foramen around the inferior ischiopubic ramus. The sling was pulled via perineal incision and refashioned into socket-like sling to house the proximal end of PP cylinder or Rear Tip Extender (RTE) (in this case). To further reinforce this connection, sling flanges wrapped around and suture fixated. Next a single-cylinder Ambicor PP (Boston Sci) is inserted. PP pump placed into the left perineal side. Total PP length was 15cm+2cm RTE. PP appeared cycling well. Skin closed in layers. Patient had an uneventful post-op course and discharged on POD #3. At the 6-week mark, the patient had no post-op complaints or complications. The patient has been able to cycle the penile implant twice daily without issue and satisfied with the outcome of the procedure. Conclusions Extra-corporal anchoring of PP cylinders using TOROS is a novel, feasible and potentially changing approach in cisgender or transgender men. Proximal anchoring of the cylinders on the inferior pubic ramus and ramus of the ischium through the modified and refashioned use of trans-obturator male sling mimic natural anatomical attachment of the proximal corpora, and the same approach can applied in a transgender man neophallus with apparent good stability with and without axial loading. Disclosure No.

Measurements of Arterial Occlusion Pressure Using Hand-Held Devices.

Vehrs, PR, Reynolds, S, Allen, J, Barrett, R, Blazzard, C, Burbank, T, Hart, H, Kasper, N, Lacey, R, Lopez, D, and Fellingham, GW. Measurements of arterial occlusion pressure using hand-held devices. J Strength Cond Res 38(5): 873-880, 2024-Arterial occlusion pressure (AOP) of the brachial artery was measured simultaneously using Doppler ultrasound (US), a hand-held Doppler (HHDOP), and a pulse oximeter (PO) in the dominant (DOM) and nondominant (NDOM) arms of males ( n = 21) and females ( n = 23) using continuous (CONT) and incremental (INCR) cuff inflation protocols. A mixed-model analysis of variance revealed significant ( p < 0.05) overall main effects between AOP measured using a CONT (115.7 ± 10.9) or INCR (115.0 ± 11.5) cuff inflation protocol; between AOP measured using US (116.3 ± 11.2), HHDOP (115.4 ± 11.2), and PO (114.4 ± 11.2); and between males (120.7 ± 10.6) and females (110.5 ± 9.4). The small overall difference (1.81 ± 3.3) between US and PO measures of AOP was significant ( p < 0.05), but the differences between US and HHDOP and between HHDOP and PO measures of AOP were not significant. There were no overall differences in AOP between the DOM and NDOM arms. Trial-to-trial variance in US measurements of AOP was not significant when using either cuff inflation protocol but was significant when using HHDOP and PO and a CONT cuff inflation protocol. Bland-Altman plots revealed reasonable limits of agreement for both HHDOP and PO measures of AOP. The small differences in US, HHDOP, and PO measurements of AOP when using CONT or INCR cuff inflation protocols are of minimal practical importance. The choice of cuff inflation protocol is one of personal preference. Hand-held Doppler of PO can be used to assess AOP before using blood flow restriction during exercise.

Determination of Sensitivity and Positive Predictive Value for Handheld Doppler in the Assessment of Thoracodorsal Artery Perforators and Literature Review

Abstract Background: Hand-held Doppler (HHD) is still a very useful tool in the reconstructive surgeon’s armamentarium. One hundred percent specificity in detecting perforators can be achieved with HHD when a perforator compression test is applied. The study aimed to determine the sensitivity and positive predictive value (PPV) for HHD in the assessment of thoracodorsal artery perforators, by applying the perforator compression test, using the color Doppler ultrasound (CDU) as the standard. Materials and Methods: This was a cross-sectional study. The Plastic Surgeon assessed for perforators using HHD on both lateral thoracic areas for each patient, with a re-evaluation of the same locations by a Consultant Radiologist using the CDU. The data generated were analysed using the Statistical Package for the Social Sciences (SPSS) software version 20, and results were presented in charts and tables. The sensitivity and PPV for HHD were then calculated. Results: A total of 70 patients were included, 58 males (82.9%) and 12 females (17.1%). The age range was 18–65 years, with a mean of 31.77 years ± 11.72 years. Overall, 247 perforators were identified by HHD. The true positive, false-positive, and false-negative values for HHD were 127 (51.4%), 120 (48.6%), and 20 (8.1%), respectively. The sensitivity and PPV for the HHD were calculated as 86.3% and 51.4%, respectively. Conclusion: The sensitivity of HHD was high while the PPV was much lower compared to other studies. This implies that for patients with positive HHD signals, the probability of having perforators intraoperative is low.

Chronic Limb Threatening Ischemia masquerading as Vitamin D deficiency; A case report

Introduction: Limb Ischemia is an uncommon but high risk emergency. It mostly presents as a painful limb in patients with peripheral arterial disease with risk factors such as hypertension, diabetes, smoking and chronic kidney disease. Timely diagnosis and intervention are crucial for reversal of ischemia. It can cause significant morbidity and mortality if left untreated due to the devastating complications. Case Presentation: We report a 42 year old healthy male who presented to the emergency department with acute pain in his left leg for 2 days. He had a history of intermittent bilateral lower limb pain and paresthesia for 2 years. Apart from well controlled Diabetes, he had no other significant medical history and reported no trauma or addictions. The patient was being managed as vitamin D deficiency by physicians at different levels of the health care system over the course of 2 years for muscular spasms and nutrient deficiency with analgesia and vitamin supplementation. Upon examination the left leg was pale, cold to touch with reduced sensation in the foot as compared to the right leg. Power of the distal left lower limb was 3 ⁄ 5. The right leg had intact sensory and motor function. No pulses were palpable in the bilateral lower limb up till the femoral artery. Findings were further confirmed via handheld Doppler ultrasound and the vascular team was emergently taken on board with the primary diagnosis of chronic limb threatening ischemia. A subsequent CT angiogram of bilateral lower limb with contrast showed complete thrombosis of the abdominal aorta below origin of renal arteries, extending from L2 vertebral level distally into the common femoral and superficial femoral arteries bilaterally along with complete attenuation on the left side of the anterior and posterior tibial, common peroneal and dorsalis pedis. The right side had similar findings with weak flow in the dorsalis pedis. The inferior mesenteric artery was also found to be occluded proximally. Patient was managed with an intravenous heparin infusion followed by urgent bilateral femoral embolectomy. Post operatively he developed pain and swelling in the lower limb for which an emergent keg leg fasciotomy was performed. Intraoperatively he was found to have extensive necrosis of anterior compartment of leg and tibialis posterior. It was followed by an extensive hospital stay secondary to sepsis and required prolonged rehabilitation and physiotherapy. Currently the patient is gradually regaining power and recovering well. Discussion: Extensive thrombosis in a young healthy male is an unusual occurrence which led to the delay in diagnosis causing significant morbidity and psychological stress to the patient. The pain that the patient had been describing for 2 years was in fact intermittent claudication. Peripheral arterial disease and its subsequent complication of chronic limb threatening ischemia (CTLI) has a dismal prognosis , significantly reducing quality of life of patients along with a substantial risk of amputation and even death. This case emphasizes the need for a detailed history and examination in young patients presenting with chronic pain, especially at the primary care level to prevent the debilitating consequences of this disease.

Supraclavicular Artery Perforator Based Flap in Reconstruction of Neck Soft Tissue Defects: Our Experience.

Neck reconstruction is challenging task as it requires achievement of both function and aesthetic form as it is exposed and visible part of body. Various reconstruction modalities like Skin graft to free flap has been described in literature (Achauer and Sood's Burns Surgery, edition 2006). We used Supraclavicular artery perforator based island Flap for resurfacing defect in Five patients. After localization of Supraclavicular artery perforator with hand held Doppler; flap was raised in subfascial plane and inset was given under anesthesia. Out of five patients, there were two males and three females. Three patients had Postburn neck contractures, one had post electrical burn defect, and one had post infective defect over neck region. All flaps survived well without any complications. Supraclavicular artery perforator based island Flap is a reliable soft tissue cover for neck defects from various etiologies.

Abstract 12762: Plasma Lipidomic Signature of Peripheral Artery Disease in Young and Middle-Aged American Indian Individuals: The Strong Heart Family Study

Introduction: Dyslipidemia is an independent risk factor for peripheral artery disease (PAD). Ankle-brachial index (ABI) is a sensitive and cost-effective tool for screening and predicting PAD. The association between individual lipid species and the progression in subclinical PAD, assessed by change in ABI, remains to be determined, especially in understudied populations at high risk. Hypothesis: To identify individual molecular lipid species associated with PAD progression in American Indians, independent of traditional risk factors. Methods: Using an untargeted lipidomic method by liquid chromatography-mass spectrometry, we repeatedly measured 1,542 individual lipid species in 2,830 fasting plasma samples at two time points (2001-2003 and 2006-2009, mean 5 years apart) from 1,415 unique American Indians in the Strong Heart Family Study. Participants were free of prevalent PAD at both time points. ABI was measured in the right arm and bilateral (both left and right posterior tibial artery) using a handheld Doppler and was analyzed as a continuous variable. We first identified baseline lipid species associated with change in ABI by generalized estimating equation models, adjusting for baseline age, sex, BMI, smoking, eGFR, diabetes, hypertension, lipid-lowering medication and baseline ABI. We then examined the longitudinal association between change in lipid species and change in ABI, adjusting for same covariates plus baseline lipids. Results: Participants (63% female) were aged between 18-65 (mean 38) at baseline and 22-72 (mean 43) at follow-up. Higher baseline levels of 36 lipid species were positively (ORs: 1.01 - 3.60), whereas 16 lipid species were inversely (ORs: 0.26 - 0.98), associated with change in ABI. Longitudinal changes in 77 lipid species, largely glycerolipids, glycerophospholipids, and sphingolipids, were significantly associated with change in ABI during 5-year follow-up. Conclusions: Baseline plasma lipid species and their longitudinal changes over time are significantly associated with PAD progression beyond known risk factors. These findings shed light on the role of dyslipidemia in PAD among young and middle-aged American Indians who suffer high rates of obesity, diabetes and other cardiometabolic disorders.