Intercostal Artery Research Articles

Strategies to avoid mastectomy skin-flap necrosis during nipple-sparing mastectomy.

Nipple-sparing mastectomy is associated with a higher risk of mastectomy skin-flap necrosis than conventional skin-sparing mastectomy. There are limited prospective data examining modifiable intraoperative factors that contribute to skin-flap necrosis after nipple-sparing mastectomy. Data on consecutive patients undergoing nipple-sparing mastectomy between April 2018 and December 2020 were recorded prospectively. Relevant intraoperative variables were documented by both breast and plastic surgeons at the time of surgery. The presence and extent of nipple and/or skin-flap necrosis was documented at the first postoperative visit. Necrosis treatment and outcome was documented at 8-10 weeks after surgery. The association of clinical and intraoperative variables with nipple and skin-flap necrosis was analysed, and significant variables were included in a multivariable logistic regression analysis with backward selection. Some 299 patients underwent 515 nipple-sparing mastectomies (54.8 per cent (282 of 515) prophylactic, 45.2 per cent therapeutic). Overall, 23.3 per cent of breasts (120 of 515) developed nipple or skin-flap necrosis; 45.8 per cent of these (55 of 120) had nipple necrosis only. Among 120 breasts with necrosis, 22.5 per cent had superficial, 60.8 per cent had partial, and 16.7 per cent had full-thickness necrosis. On multivariable logistic regression analysis, significant modifiable intraoperative predictors of necrosis included sacrificing the second intercostal perforator (P = 0.006), greater tissue expander fill volume (P < 0.001), and non-lateral inframammary fold incision placement (P = 0.003). Modifiable intraoperative factors that may decrease the likelihood of necrosis after nipple-sparing mastectomy include incision placement in the lateral inframammary fold, preserving the second intercostal perforating vessel, and minimizing tissue expander fill volume.

Intercostal artery's access for type II endoleak embolization.

Endoleaks represent a main issue of endovascular approach of thoracic aorta diseases and their treatment continue to be challenging. According to some authors, type II endoleaks sustained by intercostal arteries should not be treated because of the technical difficulties. However, the persistence of a pressurized aneurysmal may confer an ongoing risk of enlargement and/or aortic rupture. We describe the successful treatment of type II endoleak in 2 patients with an intercostal artery's access. In both cases, the endoleak was discovered during follow-up and was treated with its direct coil embolization under local anaesthesia.

Spontaneous Second Intercostal Artery Bleeding Complicated with Massive Hemothorax after Lower Limb Angioplasty Procedure

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Clinical Applications of the Intercostal Artery Perforator Flap for Trunk Reconstruction

Background Trunk defects can occur because of surgical site infections after spinal surgery, resection of malignant tumors, or trauma. Herein, we present our experience of using intercostal artery perforator (ICAP) flaps to reconstruct trunk defects without noteworthy complications. Fourteen patients underwent reconstruction with ICAP flaps between March 2015 and March 2019. Methods Patients' data, including age, sex, the cause of the defect, defect size, perforator location, flap size, complications, and follow-up period, were retrospectively reviewed. The mean age of the patients was 56.5 years (range, 19-80 years). All operations were performed after the results of bacterial culture from the wound showed no microbial growth. We found reliable perforators around the defect using Doppler ultrasonography. The perforator flaps were elevated with a pulsatile perforator and rotated in a propeller fashion to the defects. We performed five dorsal and two lateral ICAP flaps. The mean flap dimensions were 12 × 5.5 cm 2 (range, 6 × 5 to 18 × 8 cm 2 ). Results Primary closure of the donor site was performed. Marginal congestion was observed as a complication in one case, but it healed with no need for revision. The mean follow-up period was 8 months. All patients were satisfied with the surgical outcomes. Conclusion ICAP flaps can be easily mobilized, thereby reducing donor site morbidity without sacrificing the underlying muscles for trunk reconstruction. Therefore, these flaps are useful options for the reconstruction of trunk defects.

КЛИНИЧЕСКАЯ АНАТОМИЯ КРОВОСНАБЖЕНИЯ И ИННЕРВАЦИИ ПЕРЕДНЕБОКОВОЙ БРЮШНОЙ СТЕНКИ В ПРАКТИКЕ ХИРУРГА

The arterial blood supply of the anterior abdominal wall comes from the superior, inferior, and superficial suprailiac arteries, the superficial and deep arteries enveloping the iliac crest, the external genital artery, the lumbar and intercostal arteries. The innervation of the anterior abdominal wall is carried out by the intercostal nerves, branches of the iliopsoas and iliac-subiliac nerves. All of these structures may have different topography in each particular patient. Most variations will not be pathologic, but they are worth keeping surgeons in mind when performing surgical interventions. For example, in severe sclerosis of the distal arteries or aorta, or in the case of aortic coarctation, there is significant vessel dilation to provide blood supply to the lower extremities. Transection of the epigastric arteries in such cases can lead to more severe bleeding and ischemia of the lower extremities. Variation in the location of the branch of the deep inferior epigastric artery, the crown of death, occurs in 77% of patients and can cause life-threatening hemorrhagic shock. Also of clinical importance is the replacement of the areas of sensitive innervation of the iliopsoas and iliac-subiliac nerves during operations on inguinal hernia and during blockade anesthesia. Thus, surgeons need to be aware of variations in the blood supply and innervation of the anterolateral abdominal wall during surgical interventions, particularly during trocar insertion and other surgical manipulations. In order to improve surgical technique, it is suggested to introduce convenient and relatively inexpensive neuroimaging or neuromapping methods into routine practice.

Perforator-Based Cross-Midline Flaps of the Trunk: A Paradigm Shift in Flap Design.

The traditional design for truncal perforator flaps is ipsilateral without midline decussation. The presumed rationale is to minimize the risk of distal flap necrosis. In this article, the authors present their experience and results with contralateral truncal perforator flaps designed and raised crossing the midline. This retrospective analysis included 43 patients (25 men and 18 women) who underwent reconstructive surgery from 1984 to 2021 using a contralateral flap design crossing the midline in the anterior trunk and upper back. Considerations included pathology, location, and the dimensions of the defect and flap. Arithmetic and weighted means with their 95% confidence intervals were estimated to compare ipsilateral and contralateral techniques. Contralateral flaps used included the internal mammary perforator flap ( n = 28) superficial superior epigastric artery flap ( n = 8), superior epigastric perforator flap ( n = 2), and the second or ninth dorsal intercostal artery perforator flap ( n = 5). All of these flaps, excluding the superficial superior epigastric artery flap, demonstrated length and coverage surface averages that were significantly greater than those of traditional ipsilateral flaps. However, with the contralateral superficial superior epigastric artery, both measures were statistically similar to those of traditional ipsilateral flaps. The anatomical variation design suggests that the trunk midline is not a barrier and that perforator flaps in these two regions may be raised on different longitudinal axes without compromising vitality. Therapeutic, IV.

Ruptured mycotic aneurysm of intercostal arteries associated with vertebral osteomyelitis: a case report

BackgroundHere, we report a rare case of massive hemothorax caused by rupture of an intercostal artery pseudoaneurysm associated with pyogenic spondylodiscitis, which was successfully treated with endovascular intervention.Case presentationA 49-year-old man with schizophrenia, idiopathic esophageal rupture, postoperative mediastinal abscess, and pyothorax, diagnosed with pyogenic spondylodiscitis caused by methicillin-resistant Staphylococcus aureus. Magnetic resonance imaging and computed tomography (CT) showed extensive vertebral body destruction. The patient underwent a two-stage operation: anterior vertebral debridement and fixation with iliac bone graft and 10 days after first surgery, posterior fixation with instrumentation. Seven days after second surgery, the patient’s right chest pain increased, his blood pressure dropped, and he had shock. Chest X-ray showed massive hemothorax in the right lung. Chest CT and subsequent intercostal arteriography showed a pseudoaneurysm in the right T8 intercostal artery and active contrast extravasation from it. This seemed ruptured mycotic aneurysms involving intercostal vessels. These vessels were successfully embolized using micro-coils. Then, the patient completed the prescribed antimicrobial therapy in the hospital without any complications.ConclusionsIntercostal artery aneurysms are rare vascular abnormalities. They have the risk of rupture and may sometimes cause hemothorax and can be potentially life-threatening. Ruptured intercostal artery pseudoaneurysms are a good indication of endovascular intervention, and prompt embolization saved the life of the patient in this case report. This case report highlights the possibility of a ruptured intercostal mycotic aneurysm in patients with pyogenic spondylodiscitis and reminds physicians to be alert of this rare but potentially fatal complication.

Retraction: Salame et al. Is Increasing Age Associated with Higher Rates of Intercostal Arteries Vulnerable to Laceration? A Point of Care Ultrasound Study. J. Clin. Med. 2022, 11, 5788.

The journal retracts the article, 'Is Increasing Age Associated with Higher Rates of Intercostal Arteries Vulnerable to Laceration [...].

Rat Perforator and Skin Vessels Vascular Mapping: An Original Anatomical Study About 140 Vessels and Literature Review

IntroductionRecent microsurgical reconstruction techniques benefit from the use of skin and perforator flaps that spare the donor sites. Studies on these skin flaps in rat models are numerous but there is currently no reference regarding the position of the perforators, their caliber, and the length of the vascular pedicles. MethodsWe performed an anatomical study on 10 Wistar rats and 140 vessels: cranial epigastric (CE), superficial inferior epigastric (SIE), lateral thoracic (LT), posterior thigh (PT), deep iliac circumflex (DCI) and posterior intercostal (PIC) vessels. The evaluation criteria were the external caliber, the length of the pedicle, and the position of the vessels reported on the skin surface. ResultsData from the six perforator vascular pedicles are reported, with figures illustrating the orthonormal reference frame, the representation of the vessel's position, the cloud of points corresponding to the various measurements, and the average representation of the collected data. The analysis of the literature does not find similar studies; the different vascular pedicles are discussed as well as the limitations of our study: evaluation of cadaver specimen, presence of the very mobile panniculus carnosus, other perforator vessels not evaluated as well as the precise definition of perforating vessels. ConclusionsOur work describes the vascular calibers, pedicle lengths, and location of birth and arrival at the skin of the perforator vessels PT, DCI, PIC, LT, SIE, and CE in rat animal models. This work, without an equivalent in the literature, lays the foundation for future studies about flap perfusion, microsurgery, and super microsurgery learning.

Smartphone Dynamic Infrared Thermography for Harvesting AICAP Flap in a Large Breast-conservative Surgery

Flaps based on perforators of the intercostal arteries have been described for the reconstruction of defects resulting from partial mastectomies. Dynamic infrared thermography (DIRT) identifies hot spots that accurately correspond to and evaluate perforator vessels toward the skin. The new generation of portable thermal cameras has become smaller, less expensive, more sensitive, and compatible with common smartphones. One option is the FLIR ONE system (FLIR Systems, Inc., Wilsonville, OR), a smartphone-compatible thermal camera. Despite its lower resolution, compared with the larger infrared camera models, it represents a viable option for thermal skin mapping, and its compact nature allows for easy portable use. The purpose of this article is to report a case of a preoperative study with smartphone DIRT used in the preparation of an anterior intercostal artery perforator-based flap for breast reconstruction after a wide resection at the level of the right infer-internal breast region, including a skin excision. Our study documents how smartphone DIRT is a rapid, sensitive, easily accessible and cost-effective diagnostic method for the topographical identification of intercostal artery perforators. It can be used as a rescue method at any stage of the intervention if it differs from the preoperative planning. It also confirms the proven usefulness of this flap for the reconstruction of partial defects in the breast and thoracic region.

Evaluation of Anterior Intercostal Artery Perforator Flap for Oncoplastic Immediate Reconstruction Following Breast-Conserving Surgery in Lower Breast Quadrants Lesions; an Institutional-Based Study

Evaluation of Anterior Intercostal Artery Perforator Flap for Oncoplastic Immediate Reconstruction Following Breast-Conserving Surgery in Lower Breast Quadrants Lesions; an Institutional-Based Study

The Versatility of Dorsal Intercostal Artery Perforator-Based Transposition Flap for Reconstruction of Large Myelomeningocele Defects

The Versatility of Dorsal Intercostal Artery Perforator-Based Transposition Flap for Reconstruction of Large Myelomeningocele Defects

Combining a Chest Wall Perforator Flap and Bioabsorbable Implant to Facilitate Oncoplastic Breast-conserving Surgery

Oncoplastic breast conservation is classically divided into two approaches: volume displacement and volume replacement (VR). These approaches are important to use when more than 20% of the breast is removed to avoid deformity. Smaller, nonptotic breasts require VR strategies from flaps based off of local chest wall perforators. When larger volumes are required, a flap based off the thoracodorsal artery can be used. Although this flap can replace larger volumes, it usually requires a position change with increased operative time, patient morbidity, and longer recovery while also exhausting a major reconstructive modality. In an effort to avoid this increased operative complexity, we have found that combining a local chest wall perforator flap and bioabsorbable implant, which has been previously shown to be safe and effective in reconstructing partial mastectomy defects, allows for a simpler VR strategy in patients who might otherwise require a more extensive thoracodorsal artery-based flap surgery or a mastectomy. Here, we present 10 cases where we combined flaps based off the lateral, anterior or medial intercostal artery perforators or lateral thoracic artery perforator with a bioabsorbable implant to successfully perform oncoplastic breast conservation in patients who might otherwise be marginal candidates for VR using a local chest wall perforator flap.

P239 Multi-institutional Experience of Modified Lateral Intercostal Artery Perforator (LICAP) Flap Operation: Surgical and Patient Reported Outcomes (PROMs)

P239 Multi-institutional Experience of Modified Lateral Intercostal Artery Perforator (LICAP) Flap Operation: Surgical and Patient Reported Outcomes (PROMs)

The Influence of Minor Aortic Branches in Patient-Specific Flow Simulations of Type-B Aortic Dissection

Type-B aortic dissection (TBAD) is a disease in which a tear develops in the intimal layer of the descending aorta forming a true lumen and false lumen (FL). Because disease outcomes are thought to be influenced by haemodynamic quantities such as pressure and wall shear stress (WSS), their analysis via numerical simulations may provide valuable clinical insights. Major aortic branches are routinely included in simulations but minor branches are virtually always neglected, despite being implicated in TBAD progression and the development of complications. As minor branches are estimated to carry about 7–21% of cardiac output, neglecting them may affect simulation accuracy. We present the first simulation of TBAD with all pairs of intercostal, subcostal and lumbar arteries, using 4D-flow MRI (4DMR) to inform patient-specific boundary conditions. Compared to an equivalent case without minor branches, their inclusion improved agreement with 4DMR velocities, reduced time-averaged WSS (TAWSS) and transmural pressure and elevated oscillatory shear in regions where FL dilatation and calcification were observed in vivo. Minor branch inclusion resulted in differences of 60-75% in these metrics of potential clinical relevance, indicating a need to account for minor branch flow loss if simulation accuracy is sought.

Successful Embolization in Recurrent Hemoptysis Caused by Pulmonary Aspergilloma: A Case Report

Background: Aspergilloma is a fungal infection that can cause recurrent hemoptysis. One of the treatment modalities is embolization, which has a success rate of 85% to 100%, although the recurrence rate may reach 10% to 33%.&#x0D; Case Illustration: A 29-year-old female came to the emergency ward with recurrent hemoptysis. She had a history of tuberculosis with completed treatment 7 years ago. Chest radiography showed left lung tuberculosis with emphysematous lung. Chest CT with contrast revealed an air-crescent sign, and culture from bronchoalveolar lavage (BAL) showed Aspergillus spp. Then, she was diagnosed with pulmonary aspergilloma. Embolization was performed in the left internal mammary artery, and the blushing was decreased by 80%. However, the hemoptysis was still recurrent; a second embolization was performed in the left supreme intercostal artery, costocervical trunk artery, and bronchial artery, resulting in no blushing. The patient had no further episodes of hemoptysis, and her antifungal therapy was changed from fluconazole to voriconazole.&#x0D; Discussion: Recurrent hemoptysis can be caused by pulmonary aspergilloma. Embolization is usually done to reduce bleeding before surgery. The patient had performed embolization 2 times with no further episodes of hemoptysis. Surgical resection as a definitive treatment was recommended in this case, but the patient refused. Therefore, the patient’s management was optimized using voriconazole and embolization for the hemoptysis.&#x0D; Conclusion: Management of recurrent hemoptysis in patients with aspergilloma may include embolization and antifungal treatment which give improved clinical outcomes.&#x0D; Keywords: recurrent hemoptysis, embolization, aspergilloma, tuberculosis

FLOW-diverted Glue Embolization to Target lesions (FLOW-GET) technique for spinal vascular diseases: A technical note

We present and exemplify the flow-diverted glue embolization to target lesions (FLOW-GET) technique for spinal vascular diseases. In this technique, the occlusion of the posterior intercostal artery or dorsal muscular branch by coils diverts the injected glue from the segmental artery to the target lesions. This technique was applied to a ruptured retrocorporeal artery aneurysm and spinal dural arteriovenous fistulas. The FLOW-GET accomplished the complete obliteration of all lesions. This simple and useful technique can be applied to spinal vascular lesions even if a microcatheter is not placed in proper feeders or advanced close to the shunt points or aneurysms.

Delayed Arterial Bleed After Pulmonary Lobectomy

BackgroundPostlobectomy hemorrhage is rare. The majority of the bleeding happens early after surgery, with the median time to reoperation being 17 hours. Case ReportA 64-year-old man with a lung nodule underwent video-assisted thoracic surgery right upper lobectomy 3 weeks prior and presented to the Emergency Department (ED) with acute-onset chest pain and shortness of breath in the setting of delayed hemothorax from acute intercostal artery bleeding. Why Should an Emergency Physician Be Aware of This?The vast majority of the patients presenting to the ED with a hemothorax have a known history of trauma. It is important for emergency physicians to consider and recognize hemothorax in nontraumatic patients, especially those who underwent recent lung surgeries. Delayed postoperative hemorrhage is rare but possible, and can be life threatening.

Multibranched Stent Graft Modification to Preserve Intercostal Arteries during Complex Endovascular Aortic Repair

Multibranched Stent Graft Modification to Preserve Intercostal Arteries during Complex Endovascular Aortic Repair

Emergent open repair of a symptomatic type III thoracoabdominal aneurysm.

Emergent open repair of a symptomatic type III thoracoabdominal aneurysm.