Iatrogenic Vascular Injury Research Articles

Training in vascular trauma surgery for non-vascular surgeons: Vascular trauma surgery skills course.

The experience of general and trauma surgeons in vascular trauma management has decreased with sub-specialization of surgery and working hours restrictions. We introduce avascular trauma surgery skills course established to train German military surgeons prior to their deployment to conflict areas. The intention and implementation of the vascular trauma course for non-vascular surgeons is described in detail. In hands-on courses, participants learn and train basic vascular surgical techniques on more realistic extremity, neck, and abdominal models with pulsatile vessels. Afundamental and an advanced course each provide military as well as civilian surgeons from different non-vascular specialties with asurgical skill set including direct vessel sutures, patch angioplasty, anastomosis, thrombectomy, and resuscitative endovascular balloon occlusion of the aorta (REBOA) in order to render them capable of managing major vascular injuries. The experiences of this vascular trauma surgical skills course, initially established for military surgeons, can also be of use to all civilian general, visceral, and trauma surgeons occasionally facing traumatic or iatrogenic vascular injuries. Thus, the introduced vascular trauma course is valuable for all surgeons working in trauma centers.

Implementing an Educational Module for Orthopaedic Residents Placing Skeletal Traction

Although placement of a distal femoral traction (DFT) pin is a relatively simple procedure used to stabilize femoral and pelvic fractures, it places patients at risk of iatrogenic vascular, muscular, or bony injury. We designed and implemented an educational module combining theory and practical experience to standardize and improve resident teaching on the placement of DFT pins. We introduced a DFT pin teaching module into our second-year resident "boot camp," which is used to help prepare residents for taking primary call in the emergency department at our level I trauma center. Nine residents participated. The teaching module included a written pretest, an oral lecture, a video demonstration of the procedure, and a practice simulation on 3D printed models. After completing the teaching, each resident underwent a written examination and proctored live simulation involving 3D models using the same equipment available in our emergency department. Pre-teaching and post-teaching surveys were used to assess resident experience and confidence with placing traction in the emergency department. Before the teaching session, the rising postgraduate year 2 residents scored an average of 62.2% (range, 50% to 77.8%) on the DFT pin knowledge quiz. This improved to an average of 86.6% (range, 68.1% to 100%) (P = 0.0001) after the teaching session. After completing the educational module, they also demonstrated an improvement in confidence with the procedure, from 6.7 (range, 5 to 9) to 8.8 (range, 8 to 10) (P = 0.04). Despite reporting high levels of confidence in their ability to place traction pins before starting the postgraduate year 2 consult year, many residents also reported anxiety around the accurate placement of traction pins. Early results of our training program showed improved resident knowledge of safe placement of traction pins and improved confidence with the procedure.

Anatomical variations of the cavernous Internal Carotid Artery: Validation of an MRI-based classification

ObjectiveVariations of the cavernous Internal Carotid Artery (ICA) angulation (C4-bend) have been classified into 4 anatomical subtypes with particular surgical relevance, as a very angulated ICA comes in closest contact with the pituitary gland leading to higher risk of iatrogenic vascular injury. This study aimed to validate this classification using current routine imaging techniques. MethodsThe different cavernous ICA bending angles were measured on 109 MRI TOF sequences, within a retrospective database of patients with no sellar lesions. Each ICA was classified into one of 4 anatomical subtypes as already defined in a previous study [1]. Interrater agreement was assessed by a Kappa Correlation Coefficient. ResultsKappa Correlation Coefficient was of 0.90 [0.82–0.95], validating the strong level of agreement between all observers when using the present classification. ConclusionClassification of the cavernous ICA in 4 subtypes appears statistically valid on routinely used pre-operative MRI, providing an efficient tool to estimate the vascular iatrogenic risk prior to endoscopic endonasal transsphenoidal surgery.

Is an anteromedial minimally invasive approach for middle and distal third humeral fractures feasible? A cadaveric study and clinical case series

BackgroundIatrogenic injury to the radial nerve is a risk in surgical treatment for extraarticular fractures of the middle and distal third of the humerus. We aimed to investigate the safety, feasibility and advantages of minimally invasive percutaneous plate osteosynthesis (MIPPO) via an anteromedial approach in the treatment of middle and middle-distal humeral fractures and to evaluate proximity to neurovascular structures.Materials and methodsIn 2016, 13 adult cadaver arms were used to simulate a minimally invasive surgical approach to the anteromedial humerus followed by fixation with a locking compression plate (LCP), and several sets of anatomical data were measured to clarify the possible risk of iatrogenic vascular and nerve injury in this surgical approach. Then, a case series study of 12 patients with humeral fractures who were treated with this surgical approach was conducted between 2017 and 2020.ResultsThe average humeral length was 29.22 ± 1.62 cm, the average width of the medial epicondyle of the humerus was 1.31 ± 0.17 cm, and the average distance from the vertex of the medial epicondyle to the median nerve was 2.96 ± 1.62 cm. Furthermore, the safe area for distal humeral screw placement was 6.28 ± 0.39 cm, and the average distance from the tip of the distal end of the screw in the medial epicondyle to the ulnar nerve was 1.7 ± 1.25 mm. None of the 12 patients had nerve damage or an incisional infection after the operation.ConclusionsThe new approach was performed as described, and no cases of iatrogenic nerve palsy occurred. This approach can be used as an alternative for the treatment of extraarticular fractures of the middle and distal thirds of the humerus.Level of Evidence: Level IV, therapeutic study.

Open veress assisted technique for laparoscopic entry.

The creation of the pneumoperitoneum is the first step for any minimally invasive surgical procedure. Although rare, iatrogenic vascular or visceral injuries are reported and they are mainly related to the insertion of the first trocar. The Open Veress Assisted (OVA) technique allows a safe maneuver of the first trocar in order to minimize the risk of intraoperative complications during positioning of the first trocar. The purpose of this study was to describe the OVA technique and discuss the use in our current surgical practice. Each step of OVA technique is described in the text. A retrospective review of prospectively maintained institutional databases was performed to report clinical outcomes related to OVA technique use. Between December 2018 and July 2021 OVA technique was used in a total of 324 laparoscopic procedures categorized in 259 colorectal resection and 24 subtotal or total gastrectomies. No intraoperative and postoperative complications related to creation of the peritoneum occurred. OVA technique can be considered a safe alternative procedure for laparoscopic entry. By avoiding potentially dangerous insertion-related forces, this technique can be used even in previously operated patients, when the first trocar needs to be positioned away from the umbilicus or abdominal scar.

Surgical Approaches to Iatrogenic Vascular Injuries in Adults

Surgical Approaches to Iatrogenic Vascular Injuries in Adults

N-butyl 2-Cyanoacrylate (NBCA) in Nephron Sparing Superselective Embolization of Iatrogenic Renovascular Injuries: A Single Centre Experience.

Purpose To evaluate the safety and efficacy of N-butyl-2-cyano-acrylate (NBCA) for endovascular management of iatrogenic renal-vascular injuries and effects on renal function. Material & Methods Fifteen patients with diagnosed or suspected iatrogenic renal vascular injuries, following percutaneous procedures formed the study group. All the patients were having retroperitoneal hemorrhage or hematuria, with hemodynamic instability at the time of presentation. Pseudoaneurysms, active extravasation of contrast, and the arteriovenous fistula were identified as the cause of bleeding on digital subtraction angiography. Patients underwent trans arterial super-selective embolization. Renal function was monitored using serum creatinine, estimated glomerular filtration rate (eGFR), and mean blood pressure of all the patients at immediate post-procedure and two months intervals. Results Technical and clinical success was achieved in all the cases using NBCA alone. Patients improved hemodynamically. None of the patients required repeat embolization. No derangement in renal function was observed immediately after the procedure and at interval follow-up. Conclusion NBCA can be used as a safe embolizing agent to provide a quick and effective cure for iatrogenic renovascular injuries. Renal parenchymal loss can be minimized by super selective technique.

Closed reduction with percutaneous Kirschner wire drill-and-pry for pediatric supracondylar humeral fractures with bony callus formation and delayed presentation

BackgroundSupracondylar humeral fractures are the most common type of pediatric elbow fractures, and are primarily treated using closed reduction and percutaneous pinning. For patients who are treated ≥14 days after the injury, after callus formation has occurred, closed reduction is usually not possible. The purpose of this study is to report the clinical outcomes of closed reduction with percutaneous Kirschner wire (K-wire) drill-and-pry for the delayed treatment of pediatric supracondylar humeral fractures with bony callus formation. MethodsWe retrospectively reviewed the data of 16 patients who underwent percutaneous K-wire drill-and-pry between November 2019 and August 2021 for the treatment of supracondylar humeral fractures with bony callus formation ≥14 days after the injury. Clinical outcomes were assessed using the Flynn criteria. The postoperative Baumann angle and pin configuration were evaluated using x-ray examinations. ResultsAll patients were followed up for 8–28 months (average, 16.63 months). The fractures healed in 4–6 weeks (average, 4.38 weeks). The operative time ranged from 10 to 124 min (average, 35.12 min). No iatrogenic vascular or nerve injury occurred. No patient developed cubitus varus. According to the Flynn criteria, 12 patients had excellent outcomes, 2 patients had good outcomes, 1 patient had a fair outcome and 1 patient had a poor outcome. ConclusionClosed reduction with percutaneous K-wire drill-and-pry is a mini invasive technique for supracondylar humeral fractures with bony callus formation in children. Most patients had a good clinical and cosmetic outcomes without scarring.

Initial experience with Pipeline embolization of intracranial pseudoaneurysms in pediatric patients.

Flow-diverting devices have been used successfully for the treatment of complex intracranial vascular injuries in adults, but the role of these devices in treating iatrogenic and traumatic intracranial vascular injuries in children remains unclear. The authors present their experience using the Pipeline embolization device (PED) for treating intracranial pseudoaneurysms in children. This single-center retrospective cohort study included pediatric patients with traumatic and iatrogenic injuries to the intracranial vasculature that were treated with the PED between 2015 and 2021. Demographic data, indications for treatment, the number and sizes of PEDs used, follow-up imaging, and clinical outcomes were analyzed. Six patients with a median age of 12 years (range 7-16 years) underwent PED placement to treat intracranial pseudoaneurysms. There were 3 patients with hemorrhagic presentation, 2 with ischemia, and 1 in whom a growing pseudoaneurysm was found on angiography. Injured vessels included the anterior cerebral artery (n = 2), the supraclinoid internal carotid artery (ICA, n = 2), the cavernous ICA (n = 1), and the distal cervical ICA (n = 1). All 6 pseudoaneurysms were successfully treated with PED deployment. One patient required re-treatment with a second PED within a week because of concern for a growing pseudoaneurysm. One patient experienced parent vessel occlusion without neurological sequelae. Use of the PED is feasible for the management of iatrogenic and traumatic pseudoaneurysms of the intracranial vasculature in children, even in the setting of hemorrhagic presentation.

Vascular injuries associated with total knee arthroplasty

<div class="Section1"><p class="abstract">Iatrogenic vascular injuries are rare but potentially devastating complications of total knee arthroplasty (TKA). This retrospective study analyzes vascular injuries associated with total knee arthroplasties in an urban, tertiary level referral hospital between 01 April 2010 to 31 March 2020 consisting of 6548 TKAs. Six patients sustained vascular injuries which included five primary, and one revision TKAs. Three patients were bilateral, and two were unilateral primary TKAs. The mean age-adjusted Charlson’s comorbidity index was two (range 1-3). Only two injuries were recognized intraoperatively. They underwent successful vascular repair. The third patient was diagnosed and underwent a vascular repair on the first postoperative day but experienced a permanent foot drop. Two other patients underwent thrombectomy on the fifth postoperative day; one required above-knee amputation, and the other continued to suffer from vascular claudication and paraesthesia. Another patient developed a pseudoaneurysm, which was identified and repaired five months after the primary TKA. The site of vascular injury was popliteal artery in five and superficial femoral artery in one patient. The mechanism of injury was a direct laceration in three, posterior Hohman's retractor in one, the effect of tourniquet on calcified vessels in one, and unknown in one patient. Early recognition was the only factor that significantly altered the functional outcome and limb salvage. Bilateral simultaneous total knee arthroplasties had no higher risks. A mandatory institutional protocol to recognize the early signs of vascular injuries is necessary for successful vascular repair.</p></div>

Iatrogenic Vascular Injuries: A Review

Vascular injuries provide a significant challenge to emergency room staff because they call for quick action to avert loss of life or limb. Sometimes only modest or latent indications or symptoms of significant vascular damage are present. The patient may show signs of vascular insufficiency, embolization, pseudoaneurysm, arteriovenous fistula, etc., weeks or months after the initial damage. Although gunshot wounds, stabbings, and blast injuries account for the majority of vascular injuries, patients who have displaced long bone fractures, crush injuries, prolonged immobilization in a fixed position due to tight casts or bandages, and various invasive procedures should be evaluated for the possibility of vascular injury. Further investigations are required to help identify risk variables that might put a patient at more risk of suffering harm than benefiting from an intervention.

Rise in Percutaneous Vascular Procedures and Extracorporeal Membrane Oxygenation Is Associated With Increase in Emergent Vascular Operations.

Background: The workload of vascular surgeons is widely affected by the procedural activity of other departments within the same medical center. The purpose of this study was to evaluate the trend in emergent vascular surgery procedures over a 5year period in a tertiary referral hospital and categorize these procedures based on the nature of the operative procedure required. Methods: A single center, retrospective review of all emergent surgical operations performed at our tertiary referral hospital between the years 2017-2021. Data collected included types of emergent vascular surgery performed, in addition to procedures performed by the departments of interventional cardiology (IC), interventional radiology (IR), neurointerventional radiology (NIR) and extracorporeal membrane oxygenation (ECMO) at our institution. Results: During the study period were performed a total of 1783 operative procedures (mean 356 ± 26/year). Of those, 485 (27%) were emergent cases. We observed a gradual increase in emergent operative procedures performed from 2017 to 2021 (22% to 34% of all cases, increase of 56%, P<.01). A striking increase was seen with vascular repairs performed for iatrogenic vascular injuries secondary to arterial access complications (47% to 65% of all iatrogenic vascular injuries, increase of 38%). The increase correlated with an increase in activity seen in the departments of IC, IR/NIR and ECMO (15%, 31% and 300%, respectively). Conclusions: An increasing number of emergent surgical procedures performed by our vascular surgery department correlates with the increasing number of endovascular procedures performed by non- vascular services. As these procedures are expected to increase, together with the number of stroke units and ECMO units being created, medical centers must be aware that these may result in a significant increase in the workload of the vascular surgery department in order to deal with complications associated with these procedures.

Minimally Invasive Full-endoscopic Posterior Cervical Foraminotomy and Discectomy: Introducing a Simple and Useful Localization Technique of the "V" Point.

ObjectiveConventional localization technique of V point for full‐endoscopic posterior cervical foraminotomy and discectomy (FPCD) required repeated fluoroscopies, especially in patients with short and thick necks. To address this issue, the present study aimed to introduce a new localization technique of V point, and further evaluate its efficacy.MethodsA K‐wire was inserted and fixed at the pedicle eye under A/P fluoroscopy, then a working channel was established quickly along with it. Thirty‐four patients who underwent minimally invasive FPCD assisted by the new technique were included in this study. The clinical and radiological data were collected and analyzed, including radiation dose, operative time, positioning time, visual analog scale (VAS) for neck and arm pain, neck disability index (NDI) scores, Cobb angle of operative level and range of motion of the cervical spine.ResultsAll operations were performed successfully, and no iatrogenic nerve or vascular injury occurred. None of the patients needed to be transferred to open surgery or revision surgery. The mean radiation dose was found to be1.68 ± 0.36 mSv. The mean positioning time observed was 10.68 ± 5.42 min and the average operation time was 81.18 ± 10.87 min. The operation time significantly declined as the number of patients increased. A significant difference in operation time between the first (96.22 ± 10.36 min) and last quartile (75.00 ± 3.84 min) of cases was observed (t = 4.82, P < 0.001). The VAS scores for neck and arm pain, and NDI scores were significantly improved after surgery (P VAS−Neck<0.0001, P VAS−Arm<0.0001, P NDI<0.0001). Based on MacNab criteria, the excellent plus good rate was 91.17%. The Cobb angle of operative level and range of motion of the cervical spine were significantly improved postoperatively (t = 2.846, P OA = 0.015; t = 2.232, P ROM−CA = 0.026).ConclusionThe new image‐assisted V point localization technique is simple and useful with little radiation exposure and short positioning time. FPCD assisted by the new technique could be a safe and effective alternative on properly selected patients.

Early Versus Delayed Treatment for Gartland Type III Supracondylar Humeral Fractures in Children: A Systematic Review and Meta-analysis

PurposeThe timing of treatment for Gartland type III supracondylar fractures has been an area of contention as it was previously thought to be a surgical emergency. The aim of this systematic review and meta-analysis is to clarify whether there is a difference in perioperative outcomes between early and delayed treatment for Gartland type III supracondylar humeral fractures in children.MethodsLiterature search and study selection were performed according to the PRISMA process. The early surgery (ES) and delayed surgery (DS) groups were defined by the authors of each study included, based on the time to surgery. The primary outcome was the risk of conversion to open reduction. The secondary outcome was perioperative complication risks.ResultsA total of 14 studies met the eligibility criteria (n = 1263 patients), of which 665 (52.7%) patients had undergone early surgery, while 598 (47.3%) had delayed surgery. On meta-analysis, there was no significant difference between ES and DS for the outcome of open reduction conversion risk. There was also no significant difference for the secondary outcomes of post-operative compartment syndrome, iatrogenic nerve injury, vascular injury, and surgical site infection.ConclusionDespite the limitations in the literature, evidence exists to support the notion that a delayed approach to the surgical treatment of Gartland type III supracondylar humeral fractures in children does not result in an increased risk of converting to open reduction and perioperative complications.

Endovascular Management of Iatrogenic Renal Vascular Injuries: Case Series and Systematic Review.

To assess the results of RAE for the treatment of IRVI and its impact on the renal function of patients. Retrospective analysis of all patients who presented vascular complications after renal procedures and who were referred for management by RAE, between August 2012 and December 2020. 18 patients were included. 4 patients presented with pseudoaneurysm, 10 patients with active bleeding, and 1 patient with arteriovenous fistula; 2 patients had a combination of different IRVI; 1 patient did not present any findings at the time of renal angiography in dissonance with her computed tomography angiography. Technical and clinical success was achieved in all patients. One renal artery dissection was the only complication. No differences were found in serum creatinine (p = 0.51), urea (p = 0.37), hemoglobin (p = 0.26) and hematocrit (p = 0.24) after embolization. EAR is a safe and effective method for the treatment of IRVI, achieving a very high technical and clinical success rate with a low incidence of complications and without significant repercussions on the renal function of patients.

Preoperative spinal angiography decreases risk of spinal ischemia in pediatric posterior thoracic tumor resection.

Resection of pediatric posterior thoracic tumors (PTTs) can be complicated by Artery of Adamkiewicz (AKA) injury. Post-op spinal ischemia occurs in approx. 3.2% of patients, typically due to iatrogenic vascular injury. Pre-op angiography (PSA) may help to avoid this complication. Herein, we aim to evaluate outcomes after initiation of routine PSA prior to PTT resection. A single-institution retrospective review identified 25 children (< 18years) treated for PTTs from 2009 to 2021. PTTs included: posterior mediastinum, paraspinal thorax and posterior chest wall tumors. PSA patients were compared to those without pre-operative angiography (NA). Demographics, perioperative and long-term outcomes and event-free survival (EFS) were assessed. Prior to 2012, eleven patients were treated without PSA. However, the last developed post-operative paraplegia secondary to spinal ischemia. Since this event, PSA has become routine for all PTTs (n = 14) identifying six AKAs and nine accessory spinal arteries. Resection was performed in ten (90.1%) NA patients and eight (57.1%) PSA patients. Based on PSA findings, resection was not offered to six patients and planned partial resection was performed in three patients. Five PSA patients required radiation therapy for local control vs two NA patients. There were no differences in recurrence or overall EFS. PSA aids in identifying patients with high-risk thoracic vascular anatomy and may prevent risk of post-operative paraplegia associated with PTT resection.

An Institutional Experience and Literature Review on Iatrogenic Major Vascular Injury in Neurosurgery: Proposal of a Management Algorithm.

Major vessel injury is among the most dreaded complications of any neurosurgical procedure. Once intraoperatively tamponaded, it can present in the form of pseudoaneurysm, dissecting aneurysm or complete occlusion of vessel. These injuries are often associated with very high morbidity and mortality. The literature available on this topic is limited and our understanding remains limited. In this article, we present our surgical experience with iatrogenic aneurysms and present a review of literature. We conducted a retrospective analysis of all patients with major vessel injury during surgery from a prospectively maintained database from January 2012 to February 2020. A total of 15 patients developed iatrogenic aneurysms following a major vessel injury during various neurosurgical procedures. The most common vessel injured was vertebral artery (n = 9) in craniovertebral junction (CVJ) anomalies and ossification of posterior longitudinal ligament (OPLL) followed by internal carotid artery injury (n = 5) in sellar and parasellar pathologies. One patient developed basilar artery injury during endoscopic third ventriculostomy (ETV). Eight patients had pseudoaneurysm and seven had dissecting aneurysm with or without complete thrombosis of the involved artery. A total of two patients died after vascular injury and remaining thirteen patients survived and discharged. The adage "prevention is better than cure" applies most aptly in such cases. Any major vessel injury should be followed by immediate angiography and subsequent early management. The endovascular management is more favorable as these aneurysms are difficult to clip due to the absence of a neck and fragile wall.

Retroperitoneal Hematoma Caused by Lumbar Artery Injury during Percutaneous Disc Nucleoplasty: Successful Treatment Using Emergent Transarterial Embolization.

Although minimally invasive percutaneous disc nucleoplasty (PDN) has been widely used for discogenic back pain or soft-disc herniation of the lumbar spine, complications can occur. Although rare, iatrogenic vascular injuries during PDN are serious complications that can be fatal without rapid diagnosis and effective management. Here, we present the case of a 38-year-old male patient with an injury to the right fifth lumbar artery that occurred during PDN, which was successfully treated using emergent transarterial embolization. To the best of our knowledge, this is the first report of successful transarterial embolization without open hematoma evacuation for a lumbar artery injury that occurred during PDN.

Dental Silicone-based Surgical Guides to Harvest the Chimeric Scapular Flap: Preventing Iatrogenic Vascular Injury.

Summary:The angular branch of the thoracodorsal artery and the periosteal branches of the circumflex scapular artery can be easily injured while harvesting a chimeric scapular flap. Thus, we reported the use of 3D printed scapular models using CT angiography to prepare inexpensive surgical guides from autoclavable dental silicone impressions for scapular flap harvest. Mandibular and scapular models were prepared using a 3D printer for 11 patients undergoing chimeric scapular flap transfer following mandibular resection. During preoperative simulation surgery, we molded dental silicone accordingly with scapular models to produce surgical cutting guides. Six men (54.5%) and five women (45.5%) were included. The average age of patients was 65.4 years. Fourteen bone units were reconstructed as three patients needed two bone segments (27.3%) whereas eight patients required reconstruction of one bone segment (72.7%). The mean flap harvest time and total surgical time were 52.1 min and 633.8 min, respectively. The mean duration for osteotomies and bone plate fixation was 26.2 min. The difference between the length of the preoperative surgical model (64.92 mm) and the postoperative 3D-CT measurements (64.48 mm) was not statistically significant (0.95 mm, P = 0.397). No injuries were caused to the angular and periosteal vessels. Four patients exhibited donor-site seroma (36.4%). The cost of the dental silicone for surgical guide was only $5 per patient. Dental silicone-based surgical guides help minimize the risk of vascular injury while harvesting chimeric scapular flaps. The osteotomies were performed with precision and in a time-efficient manner.

Minimalinvasive Chevron- und Akinostetomie: Muss man jetzt umsteigen?

Percutaneous osteotomies for the treatment of forefoot deformities have become increasingly popular in recent years. The main advantage is less soft tissue damage and aesthetic benefits. The disadvantage is the lack of visualization of the surgical field. Therefore, a precise anatomical knowledge and understanding of these techniques are required.The initial procedures of percutaneous hallux valgus surgery had a high complication rate due to limited technical capabilities, designs of osteotomies, and osteosyntheses used. The combination of established procedures, indications, and percutaneous techniques has been able to significantly advance the techniques. Even severe deformities can be corrected by the modified osteosynthesis of minimally invasive Chevron- and Akinosteotomy while preserving the soft tissue mantle. MethodAfter implementation of minimally invasive Chevron and Akinosteotomy, we evaluated the first 93 patients from the first 12 months with regard to operation time, radiation exposure and complication rate and compared them with conventional scarf and akinosteotomy. ResultsWhile a learning curve cannot be avoided, this relates particularly to operative times and radiation exposure. It was shown that the modified screw osteosynthesis and less the percutaneous osteotomy is the real challenge. With appropriate courses and training on the cadaver, complications can be avoided. SummaryFears of increased iatrogenic tendon, nerve, and vascular injuries during the learning curve have not been confirmed. In the meantime, the minimally invasive chevron and akinosteotomy (MICA) could develop into the standard procedure for the correction of moderate to severe hallux valgus deformities in our clinic. It is a safe and reproducible procedure.