Lateral Artery Research Articles

Case report: lateral axillary-profunda femoris artery bypass for acute lower limb ischemia due to thrombosis after bilateral axillofemoral bypass

IntroductionWe treated a patient with late-stage unilateral bypass thrombosis after bilateral axillary-femoral bypass with lateral axillary-profunda femoris artery (LAx-PF) bypass.Case presentationA 64-year-old male patient was admitted to our hospital for acute left lower limb ischemia. Six years ago, he underwent bilateral axillary-femoral bypass due to Leriche syndrome. On emergency admission, thrombosis of the left bypass vessel was identified. Blood flow could not be restored due to failure to restore patency of the proximal and distal anastomosis of the left bypass vessel during surgery. We performed LAx-PF bypass surgery to successfully rescue the limb, which was on the verge of necrosis.ConclusionIf thrombectomy cannot restore blood flow in the previous axillary-femoral bypass, LAx-PF bypass is an easy procedure to rescue the ischemic limb.

Assessment Of Lateral Costal Artery With Ct-angiography: Importance For Patients Undergoing Coronary Artery Bypass Grafting

Assessment Of Lateral Costal Artery With Ct-angiography: Importance For Patients Undergoing Coronary Artery Bypass Grafting

Lenticulostriate arteries appearance before thrombectomy predicts good outcome in acute middle cerebral artery occlusion

BackgroundEndovascular therapy is widely used in acute large vessel occlusion. This study investigated whether imaging of lateral lenticulostriate arteries (LSAs) before thrombectomy would potentially be helpful for predicting prognosis of patients with acute M1 segment of middle cerebral artery occlusion (MCAO).Methods59 consecutive patients with acute M1 segment of MCAO treated with mechanical thrombectomy at two comprehensive stroke centers were analyzed. Patients were categorized into LSA+ (appearing of lateral LSAs) and LSA- (sparing of lateral LSAs) group according to preprocedural digital substraction angiography (DSA). Baseline data and clinical outcomes were compared. A good clinical outcome was defined as a modified Rankin Scale score of 0 to 2 at 3 months. The association between clinical and imaging parameters and functional outcome was evaluated with logistic regression analysis.ResultsLSA+ was shown in 36 patients (61%). LSA+ group had a significantly higher proportion of good outcome (72.2% vs. 8.7%, OR 27.3,95% CI 5.38–138.4, P < 0.001), lower risk of symptomatic intracranial haemorrhages (sICH) (8.3% vs. 47.8%,OR 0.10,95% CI 0.02–0.42, P = 0.001) and lower mortality in hospital (5.6% vs. 34.8%, OR 0.11,95% CI 0.02–0.58, P < 0.004) compared with LSA- group. Patients in LSA+ group had lower baseline NIHSS score(P < 0.01) and NIHSS score at 14 days(P < 0.01) and smaller infarct core volume (P = 0.016) on computed tomography perfusion imaging (CTP) compared to the LSA- group. Multivariate logistic regression analysis showed that a small infarct core volume (OR 6.74,95% CI 1.148–39.569, P = 0.035) and LSA+(OR 22.114,95% CI 3.339–146.470, P = 0.001) were associated with a good clinical outcome.ConclusionsOur data suggest that appearance of lateral LSAs before mechanical thrombectomy would be potentially helpful for predicting favorable prognosis of patients with acute M1 segment of MCAO.

A unique temporary collateral pathway between carotid-vertebrobasilar arteries in a carotid dissection patient

BackgroundIn adults, the anastomosis between carotid and vertebrobasilar arteries is usually the posterior communicating artery, sometimes the primitive trigeminal artery. In this case, the basilar artery fed the internal carotid artery through the pontine-to-tentorial artery anastomosis after severe stenosis from traumatic carotid dissection.Case presentationA 32-year-old female was diagnosed with ischemic stroke caused by traumatic carotid artery dissection. Aspirin (100 mg/day) and clopidogrel (75 mg/day) were prescribed. Digital subtraction angiography performed 6 days after stroke onset showed a dissection in the cervical segment of left internal carotid artery with severe local stenosis, and a collateral pathway from BA to the cavernous segment of internal carotid artery through the lateral pontine and tentorial artery. Without interventional therapy, clinical symptoms improved significantly within 10 days after onset. At 3-month follow-up, left common carotid artery angiography showed the stenosis had been significantly improved with a residual aneurysm. There was no collateral pathway between carotid-vertebrobasilar arteries, and a residual small artery originated from the posterior vertical segment of cavernous internal carotid artery. The small artery was clearly visualized by 3-dimensional rotational angiography and identified the tentorial artery.ConclusionTo the author’s knowledge, this is the first report of a collateral pathway between carotid vertebrobasilar arteries through the pontine-to-tentorial artery anastomosis. Meanwhile, tentorial artery origination directly from the cavernous segment of internal carotid artery is rare and easily mistaken for persistent primitive trigeminal artery. 3-dimensional rotational angiography can provide sensitive and accurate diagnostic assessment of the small artery, and may be a useful tool for screening of abnormal small arteries.

Cadaveric study of variations of origin of lateral circumflex and medial circumflex artery in a Sri Lankan population

Cadaveric study of variations of origin of lateral circumflex and medial circumflex artery in a Sri Lankan population

Asymmetrical than symmetrical cerebral arterial bifurcations are more vulnerable to aneurysm presence

In order to investigate the role of lateral angle ratio (LA ratio) and daughter artery ratio (DA ratio) for predicting aneurysmal presence in main cerebral arterial bifurcations, three-dimensional cerebral angiographic data of major cerebral artery bifurcations were used for measurement of artery diameters and bifurcation angles including 115 middle cerebral arteries (MCAs), 59 basilar arteries (BAs), 35 internal carotid arteries (ICAs) and 115 anterior cerebral arteries (ACAs) with bifurcation aneurysms and control subjects of 1921 bifurcations with no aneurysms. The LA ratio (larger lateral angle/smaller lateral angle) and DA ratio (larger branch diameter/smaller branch diameter) were calculated, and ROC curve analysis of LA and DA ratios between normal and aneurysmal cases was performed. The LA and DA ratios of MCA bifurcations and the LA ratios of BA and ICA bifurcations with aneurysms were all significantly larger than normal bifurcations (P < 0.05), and the DA ratio of ACA bifurcations with aneurysms was significantly smaller than normal cases (P < 0.01). Moreover, the LA ratio or DA ratio between the normal and aneurysm cases in MCA, BA and ACA bifurcations demonstrated significant differences by ROC analysis (P < 0.01) except in the ICA bifurcations. No significant difference was observed (P > 0.05) between ruptured and unruptured aneurysms in MCA, BA, ICA and ACA bifurcations. In summary, normal MCA, BA and ICA bifurcations show symmetrical morphology in the lateral angles and daughter branches, whereas aneurysmal bifurcations show asymmetrical morphology. Normal ACA bifurcations have asymmetrical bilateral daughter branches while symmetrical branches are associated with ACA bifurcation aneurysm presence.

P1963The determinants of functional significance of coronary bifurcation lesions and its implications on clinical follow up to 48 months (insights from FIESTA registry)

Abstract Background There is no study up-to-now to determine the rate of functionally significant coronary bifurcation lesions, which have to be intervened and what are the clinical consequences of the FFR case selection strategy. Methods We analyzed patients from FIESTA registry, which was continuation of FIESTA study (Ffr vs. IcEcgSTA, ClinicalTrials.gov Identifier: NCT01724957). Patients with stable angina were included (if there were other coronary stenoses they were threated first after checking by FFR for functional significance). The inclusion criterions were angiographic bifurcation lesions in a native coronary artery with diameter ≥2.5 mm and ≤4.5 mm and SB diameter ≥2.0 mm. We excluded patients with ST-segment elevation myocardial infarction, left main, hemodynamic instability and those with non-cardiac co-morbidity conditions with a life expectancy of less than one year. PCI was performed according to the current guidelines. Provisional stenting was the default strategy in all patients. Two guidewires were inserted into both distal MB and SB. Initial FFR was performed using the PrimeWire or PrimeWire Prestige (Volcano Corp., USA). For all FFR measurements, intracoronary adenosine was given in increasing doses of 60 mcg, 120 mcg, and 240 mcg. The minimum value of FFR measurements was taken for analysis. All patients received double antiplatelet therapy with ADP-antagonist and aspirin for at least 12 months. Results A 130 consecutive patients with coronary bifurcation stenoses were included – 57 had positive FFR&lt;.80 in main vessel of bifurcation lesion (44% functionally significant lesions). The mean age was 67±10 years, 66% males, 96% hypertensive, 39% diabetic, 96% dyslipidemic (or on treatment with statin), 55% smokers, 22% with previous myocardial infarction, 51% with previous PCI. The residual SYNTAX score before FFR bifurcation assessment was 13±4 (FFR&lt;.80) vs. 8±3 (FFR≥0.80), p&lt;0.001. Univariate predictors of bifurcation FFR&lt;.80 were: proximal (MV%DS) or distal (MB%DS) main vessel stenosis ≥85% (derived from ROC analysis with overall accuracy 77% and 72%, accordingly), lesion length, SYNTAX score, triglyceride concentration, previous MI on lateral wall and carotid artery disease. On multivariate logistic analysis only MV%DS&gt;85% (OR=8.929, CI 2.887–27.619, p&lt;0.001), MB%DS&gt;85% (OR=3.831, CI 1.349–10.883, p=0.012) and SYNTAX score≥12 (OR=16.466, CI 5.225–15.889, p&lt;0.001). At median follow-up of 26 months (IQR 17–35) the all-cause mortality was 17.5% in FFR positive bifurcations vs. 4.1% in FFR negative lesions (log-rank =.067). Conclusions Less than a half of angiographically significant coronary bifurcation lesions are functionally significant and require stent implantation. The functional significance was related with higher degree stenosis in main vessel and overall disease severity estimated with SYNTAX score. A trend to lower mortality was noted in group with non-significant FFRs.

Branching Pattern of the Medial Calcaneal Neurovascular Bundle in Porta Pedis of the Human Foot

The medial calcaneal nerve (MCN) is the first branch of the posterior tibial nerve (PTN) in the porta pedis, enervates the skin of the heel and medial side of the foot. Heel pain is a common condition encountered by physicians, and this may have a significant clinical association with the MCN’s branching pattern. This study was to identify branching pattern variations in the medial calcaneal neurovascular bundle. This study was carried out using 60lower limbs of formalin-embalmed cadavers, using the tarsal tunnel dissection method for 30right and 30 left lower limbs. The medial calcaneal neurovascular bundle course was identified by exposing the PTN and its branches from the distal end of the leg toward the plantar surface beyond its bifurcation and resecting the skin and flexor retinaculum. Many MCN branching pattern variations (specifically concerning origins, numbers, and levels of branching) were observed. In the right foot a single branch was present in 21 specimens (70%), while two branches were observed in nine specimens (30%). In the left foot, a single branch was present in 22 specimens (73.3%) and two branches were present in 8 specimens (26.7%). In this study, two branches originate from lateral planter artery is the most common observation. This study concludes that a single MCN originating from the TN is the most common variant. Two medial calcaneal arteries (MCAs) originating from the LPA is also common.

Combined anterolateral thigh and tensor fasciae latae flap using intraflap flow-through anastomoses in a case of chest wall reconstruction

We report a 74-year-old man with malignant tumor of the chest wall. He underwent wide local excision and reconstruction with combined free anterolateral thigh (ALT) and tensor fascia latae (TFL) flap using intraflap flow-through anastomoses. The designed flap was 20 × 11 cm in size; however, the flap pedicles of the ALT perforators were smaller than expected. Considering that the ALT perforators would not have yielded a sufficient perforasome, we included TFL perforator in the flap. Intraflap anastomosis of the artery and vein of the TFL perforator was performed with the distal end of the descending branches of the lateral circumflex artery and vein. This combined flap was transplanted to cover the chest wall defect. The flap healed without postoperative complications. This report shows that intraflap anastomoses for two different pedicles can be useful for no more than one artery and vein at the recipient site and also allows for preservation of the other lateral circumflex branches. Level of evidence: Level V, therapeutic study.

Surgical Clipping for Complex Middle Cerebral Artery Aneurysm: Decision-Making Tree With Tailored Bypass Strategy

Abstract INTRODUCTION Bypass surgery is important as an effective strategy for complex middle cerebral artery (MCA) aneurysms. Various bypass techniques were reported, but some of them were challenging and difficult to understand. The aim of this report was to propose our simple and flexible method for selecting ideal bypass option and its outcome. METHODS The strategy of bypass surgery is modified by a consideration of the anatomical situation as follows: Is it possible to make a flow our route? Is the amount of bypass flow sufficient? How is the location of lateral lenticulostriate artery (LSA)? Is the preservation of M2 branches possible? Modality of bypass surgery consists of (1) standard superficial temporal artery (STA)-middle cerebral artery (MCA) bypass (single/double, M3/4), (2) STA-proximal MCA (single/double, M1/2), (3) high flow bypass, (4) in-situ bypass (MCA-MCA parallels), and (4) interposition bypass. Operative strategy is selected based on our decision making tree. RESULTS Between 2015 and 2018, we experienced 280 cases (70 ruptured, 210 unruptured) of direct surgery for cerebral aneurysms. Of these cases, the MCA aneurysm accounted for 40% (112 cases). Among these, revascularization was required in 10 cases of complex anatomy. Strategy of bypass surgery included the following: STA-proximal MCA (M1) single bypass: 1 case, STA-proximal MCA (M2) single bypass: 3 cases, STA-proximal MCA (M2) double bypass: 3 cases, STA-distal MCA (M3-4): 1 case, and MCA-MCA in situ bypass: 2 cases (include combination bypass). Patency of bypass was 96% and neurological worsening that caused by surgery was 20% with no operative mortality. CONCLUSION Our decision-making tree with tailored bypass strategy is reasonable and will help select an optimal strategy for the complex MCA aneurysm surgery.

04:21 PM Abstract No. 295 CT-guided vascular interventions using ultra-low-dose CT fluoroscopy and 4D CT DSA: a feasibility study

Ultra-low-dose CT fluoroscopy (ULD-CTF) is a recently developed technique that significantly increases the temporal resolution and decreases radiation exposure during CT fluoroscopy. 4D CT DSA is a method for performing time-resolved CTA and flow quantification in a 3D vascular volume. The purpose of this study was to determine the feasibility of using ULD-CTF and 4D CT DSA to perform vascular interventions in an in vivo porcine model. Under intermittent CT guidance, a 5Fr catheter was placed in the descending thoracic aorta of an ∼50kg female swine and a CTA of the abdomen was acquired. This CTA was motion corrected and combined with ongoing catheter reconstructions using ULD-CTF. Four CT projections per gantry rotation (gantry rotation time 0.5s) were used to reconstruct the catheter with 8 frames/sec. The reconstruction of a single time frame of the catheter was performed using two projection images separated by a 90-degree angle. To evaluate the accuracy of the intravascular device reconstruction, intermittent CT was performed as the catheter was guided through the aorta into the splenic artery. Traditional roadmap and endovascular views were created. Subsequently, the catheter was repositioned into the common hepatic artery. 4D CT DSA images were obtained and flow within the main hepatic arteries calculated. The localization error of the catheter tip on ULD-CTF was 2.70±0.73 mm compared to the conventional reconstruction. Reconstructing the catheter with only 4 projections per gantry rotation enables a relative radiation dose reduction of up to 250× compared with conventional reconstruction. Flow values in the hepatic arteries were: common hepatic (1.74ml/s), gastroduodenal (0.33ml/s), left hepatic (0.95ml/s), left medial (0.89ml/s), left lateral (0.42ml/s), right medial (0.96ml/s) and right lateral (0.84ml/s and 0.84ml/s) arteries. Flow conservation within the vascular volume was 86.44%. ULD-CTF and 4D CT DSA are feasible and, when combined, may enable quantitative CT-guided vascular diagnosis and interventions in the future.

Systematization and Description of the Arterial Blood Supply of the Paleopallia areas in the Brain Surface of the Wild Boar (Sus scrofa scrofa)

Background: The study was performed on wild boar (Sus scrofa scrofa) wich is a wild ancestor of the domestic pig and is not part of Brazilian fauna. The arterial blood supply of the encephalus has been studied by some researchers, who have systematized the cerebral blood supply from the rostral and caudal epidural rete mirabile and its sources in wild boar until the blood supply of the base of the brain. The objective was to improve the understanding of the arterial blood supply of the brain, particularly the paleopallium, of the wild boar and to provide a reference for comparative anatomy studies. Materials, Methods &amp; Results: A total of 30 brains were obtained from an officially authorised slaughterhouse and approved by Brazilian Institute of Environment and Natural Renowable Resources. The animals were desensitized, followed by bleending of the jugular veins and common carotid arteries near the entrance of the thorax, according to the slaughter procedure. Finally, the animals were decapitated at the level of axis vertebra. The cerebral arterial system of each animal was rinsed (cooled saline containing 2500 IU of heparin) and drained by the jugular veins, and vessels were filled with latex 603 stained with specific red dye. The heads were submerged for one hour in running water immersed in 20% formaldehyde for fixation; the brains were removed along with a cervical segment of the spinal cord. The duramater was removed, and the arteries were dissected. Schematic drawings of the ventral view of the all preparations were made using magnifying glasses and photographic records. The Nomina Anatomica Veterinaria was used to named the cerebral arteries and their branches, and calculation of pecentages was applied in the statistical analysis. The cerebral carotid artery originating from the rostral epidural rete mirabile emitted a rostral branch and a caudal branch on the side of the hypophysis gland. The rostral branch emitted one to three middle cerebral arteries and continued as rostral cerebral artery. The latter emitted the superficial and perforating central arteries, lateral rhinal artery, ethmoidal artery, medial branch and medial rhinal artery. Discussion: Wild boar is a macrosmatic animal, it presents well-developed areas of the paleopallium that are exclusively olfactory. Its extensive paleopallium was nourished by branches of the rostral cerebral artery and its collateral branches, including the lateral rhinal, ethmoidal, and medial branch and the medial rhinal artery. The rostral cerebral arteries and their collateral branches supplied blood to the olfactory bulb, olfactory peduncle, two-thirds of the lateral olfactory tract, medial olfactory tract, and rostral two-thirds of the olfactory trigone. The medial cerebral arteries within the lateral fossa of the brain, emitted superficial rostral central branches to the paleopallium, perforating central branches (striated) to the lateral fossa of the brain and caudal third of the olfactory trigone and caudal central branches to the piriform lobe. The rostral most two-thirds of a small medial band of the piriform lobe was vascularised by central branches originating mainly from the rostral branch of the cerebral cartotid artery. The paleopallium in the wild boar was nourished by branches of the cerebral rostral, middle and caudal arteries and by the central branches of the cerebral carotid artery. The arterial blood supply of the paleopallium in the wild boar was compared to the chinchilla, nutria, rabbit and pampas fox. Three cerebral vessels were mainly responsable for the emission of the central branches that supplied blood to the paleopallium, namely the middle, rostral, and caudal cerebral arteries. The differences or variations among these species were due to the type of cerebral blood supply in the formation of the cerebral arterial circle.Keywords : anatomy, brain, paleopallia, arteries, Artiodactila, wild boar.

Abstract WMP120: The Role of Age, Lesion Location and Volume in Predicting Long-Term Neurological Outcomes in Pediatric Ischemic Stroke

Introduction: The balance of plasticity versus vulnerability to acute ischemic injury in the immature brain across development remains controversial. We aimed to investigate the relationship between age at stroke and lesion location and volume with long-term outcomes following arterial ischaemic stroke (AIS). Hypothesis: Age at stroke onset interacts with lesion location and volume to predict long-term neurological outcomes. Methods: In a single-centre prospective study, children aged term birth to 18 years with acute symptomatic AIS from 1992 to 2016 who underwent neuroimaging (CT/MRI) within 14 days of stroke onset were studied. Long term outcomes were assessed with the Pediatric Stroke Outcome Measure (PSOM). Outcomes were defined as normal (score 0-0.5 on 1-5 PSOM subscales), otherwise abnormal. AIS lesions were classified based on major (anterior, middle, posterior, other) cerebral arteries and branch sub-territories (e.g. MCA-lateral lenticulostriate). For each vascular territory, the proportion of infarcted brain was estimated as ‘small’ (≤50% territory) or ‘large’ (&gt;50% territory). Factors predictive of long term outcomes were evaluated using logistic regression models. Results: Among 285 children, median age at stroke onset was 22 months (IQR: 0.03-101), 41% were females. PSOM scoring at median 9 years (IQR: 4-15) post-stroke was normal in 61%. Abnormal outcome was associated with age 1-4 years (OR=2.2, 95% CI: 1.02-4.9), ‘large’ proportion infarcts involving cortex within any major artery territory (OR=6.1, 95% CI: 2.6-14.4), and subcortical infarcts: OR= 2.7 (95% CI: 1.4-5.4) for small proportion infarcts; OR=8.3 (95% CI: 4.2-16.6) for large proportion infarcts in either medial or lateral lenticulostriate arteries; OR=15.8 (95% CI: 5-50.3) for large volume lesions in both lenticulostriate territories. In multivariate logistic regression, age, cortical and subcortical infarcts predicted long-term neurologic outcomes. Conclusions: In addition to age at stroke onset, infarct location including volume plays a key role in predicting long-term neurological outcomes in children. While the relationship between age and neurological outcomes seems to be bimodal, a linear effect of lesion volume on stroke outcomes is evident.

Сolor Doppler Imaging in Eye Hemodynamics Evaluation in Syndrome of Thrombotic Microangiopathy

Purpose.To assess the state of blood flow in retrobulbar vessels using the method of color Doppler imaging in thrombotic microangiopathy (TMA) associated with atypical hemolytic uremic syndrome (aHUS), malignant hypertension (MH) and catastrophic antiphospholipid syndrome (CAPS).Methods. The study involved 16 patients aged from 18 to 43 years with TMA associated with aHUS (13 patients), MH (2 patients) and CAPS (1 patient). All patients underwent a study of the state of blood flow in the vessels of the retrobulbar space by color Doppler imaging using a multifunctional ultrasonic diagnostic device Voluson 730 Pro and Voluson E8. The spectrum of blood flow in the ophthalmic artery (OA), central retinal artery (CRA), central retinal vein (CRV), in the medial and lateral short posterior ciliary arteries (SPCA) was recorded and the following parameters were determined: maximum systolic velocity (Vsyst), final diastolic velocity (Vdiast), peripheral resistance index (RI), pulsation index (PI).Results. The analysis of the Doppler blood flow spectrum in all patients with TMA syndrome revealed a decrease in Vsyst in the vessels of the retrobulbar space, more pronounced in the CRA, with an increase in the venous component of the Doppler spectrum. In patients with TMA associated with aHUS and MH Vdiast in the studied vessels were in normal limits or increased, RI and PI were reduced. In aHUS a statistically significant correlation was found between Vdiast in OA and the level of haptoglobin in blood serum, which is a classic marker of intravascular hemolysis.Conclusion. Color Doppler imaging of retrobulbar vessels is an important method for the diagnosis of ocular hemodynamics disorders in the syndrome of TMA. All patients with TMA syndrome are characterized with a decrease in the systolic component of the Doppler spectrum of blood flow in the vessels of the retrobulbar space, especially in the CRA, with an increase in the venous component. With aHUS and MH diastolic blood flow in the retrobulbar vessels corresponds to the norm or increases, RI and PI decrease. In TMA associated with aHUS, the final diastolic velocity of blood flow in OA depends on the level of microvascular hemolysis.

Late bleeding during anterior approach to the hip: case Report.

Vascular injuries represent an uncommon complication of total hip arthroplasty, with an incidence of 0.1-0.3% as reported in the literature. The aim of the study is the description of a case of late bleeding in a female patient undergoing surgery for total hip arthroplasty in right osteoarthritis through direct anterior approach. The treatment carried out was a selective embolization of the main ascending branch of the lateral circumflex artery. This was performed by placing two spirals following an angiography, which was revealing an active spreading of contrast at the right femoral circumflex ascending artery. The effectiveness of endovascular techniques for the treatment of early and late bleeding after surgery is pointed out. (www.actabiomedica.it)

Atypical location of ST elevation acute myocardial infarction in relation to the electrocardiogram

Introduction. Electrocardiography is an initial non-invasive diagnostic algorithm for ST elevation acute myocardial infarction. Specific electrocardiographic phenomenon is described, when the occlusion of the proximal segment of the right coronary artery or the isolated occlusion of its ventricular branch is presented with ST elevation in the precordial leads. Case Report. A 78-year-old woman was admitted as an emergency due to chest pain and electrocardiographically recorded concave elevation in leads V1 - V3. She was diagnosed with ST elevation myocardial infarction of the anterior region and sent to catheterization laboratory for emergency coronary angiography. It showed an occlusion of the proximal-medial right coronary artery. Behind the occlusion, the right coronary artery, posterior descending artery and posterior lateral artery, a hetero-collateral circulation was seen. Two drug-eluting stents were implanted into the proximal segment of the right coronary artery. Discussion. The phenomenon of acute myocardial infarction caused by occlusion of the proximal right coronary artery and/or ventricular branches of the right coronary artery, presenting with ST segment elevation in the precordial leads, is a consequence of several anatomical variations: occlusion of nondominant right coronary artery, isolated occlusion of the ventricular branch of the right coronary artery, and the occlusion of the right coronary artery proximal to the ventricular branch with hetero collateral circulation on the periphery of the right coronary artery, like in our case. Electrocardiographic characteristic pointing to the occlusion of the proximal right coronary artery and/or ventricular branches of the right coronary artery is higher ST elevation in the lead V1 than in the other leads, followed by the absence of Q wave development. This ST elevation is concave. Conclusion. It is necessary to emphasize the significance of differential diagnosis of culprit lesion in patients with chest pain and elevation of the ST segment in the precordial leads having in mind further different thera peutic algorithms. Patients with right ventricular myo cardial infarction need to maintain an adequate ?preload? and avoid vasodilators in order to maintain the right ventricular stroke volume.

Repair of large area of soft tissue defect of calf by the retrograde anterolateral thigh flap with single high cutaneous perforator

Objective To explore the clinical effect of repairing the large area of soft tissue defect of the calf by the retrograde anterolateral thigh flap with single high cutaneous perforator. Methods From January, 2014 to July, 2017, 9 cases of large area of soft tissue defects were repaired by the retrograde anterolateral thigh flap with single high cutaneous perforator. There were 7 males and 2 females, aged 24-48 years. Soft tissue defects area of the calf was 10.0 cm×7.0 cm to 35.0 cm×15.0 cm, including skin grafting and skin stretch to repair the area. The perforating point of the high cutaneous artery branches was designed at the proximal end of the flap, which was used as the single nutrient vessel of the flap. The rotation point of the flap was moved upward to the proximal thigh, which not only increased the blood supply of the flap, but also made the flap repair range to the distal calf. The flap range was 15.0 cm×10.0 cm to 22.0 cm×12.0 cm. Results All flaps were cut smoothly, and no vascular crisis occurred. All flaps survived smoothly. All patients were followed-up for 6-12 months. The appearance of flaps was plump, slightly bloated, and their color was similar to the recipient area. The texture was soft, and no active disorder in the donor site. Conclusion The retrograde anterolateral thigh flap with single high cutaneous perforator can be designed at a high rotation point. By increasing the number and caliber of the anastomotic branch between the pedicle and lateral superior genicular artery, the blood supply and reflux of flap can be improved, and the survival rate is not affected. Compared with the traditional anterolateral thigh flap, it has great advantages. Key words: Anterolateral thigh flap; High cutaneous perforator; Lower leg; Soft tissue defect

Integrated expanded flaps for the chest and trunk reconstruction in patients with post-burn total and subtotal scars

The aim — to improve the surgical treatment results in patients with post‑burn total and subtotal deformations of the chest and trunk with expanded flaps based on axial and perforating vessels.Materials and methods. The work is based on examinations of 16 patients (10 women and 6 men) with subtotal and total post‑burn deformities of the chest (8), abdominal wall (4), chest and abdominal wall (3) and the posterior lateral surface of the trunk (1) in age from 5 to 38 years (average 15.3 years). To eliminate the deformities, a pre‑expanded 21 integrated flaps based on the perforator vessels of the lateral artery of the chest and VI‑VII of the middle perforators of the intercostal arteries (5), VI‑X of the middle (6) and VI‑X of the anterior (3) perforators of the intercostal arteries, I — II perforators of the lumbar arteries (6) and perforators of the deep lower epigastric artery (1) were used.Results and discussion. The possibility of the integrated expanded flaps formation from the lateral surface of the chest and trunk on the basis of axial and perforator vessels based on axial and perforator adjacent areas due to the reconstruction of the vascular bed and tissue hemodynamic was shown.Conclusions. Clinical data of use of integrated expanded flaps from the lateral surface of the chest and abdominal wall based on axial or perforator vessels and the vascular network of perforator vessels of adjacent tissues allowed to obtain good (73.8 %) and satisfactory (26.2 %) results in the nearest and good (64.3 %) and satisfactory (33.7 %) results in the remote follow‑up period.

Contribution to the Vascularization of Cruciate Knee Ligaments and its Relevance in Trauma Surgery

The intercondyloid notch of the knee, has acquired interest from the surgical point of view, with the use of technical arthroscopy in the treatment of anterior and posterior cruciate ligaments. This review shows the arterial branches that receive cruciate ligaments in different areas and confirms the presence of periligamentous anastomotic networks. The study included 6 adult knees and 14 fetal human knees between the 6th and 8th month of gestation, for artery and cruciate ligament analysis through transverse and frontal slice dissections. In conclusion cruciate ligaments receive their principal vascular contribution, through the medial artery of the knee and secondarily from inferior medial and lateral arteries. In the fetal stage there were periligamentous arterial connections in the femoral insert of both ligaments. Anatomical knowledge of the arteries that approach cruciate ligaments is important in repairs as it favors vitality and good joint mechanics.

Surgical treatment of lenticulostriate aneurysms (a case report and literature review)

The study objective is to describe a rare case of putaminal intracerebral hemorrhage (PICH) results from a rupture of the distal lateral lenticulostriate artery (LSA) aneurysm and to summarize currently available information on its diagnosis and treatment.Materials and methods. A 40-year-old female patient was admitted to the N.V. Sklifosovsky Research Institute of Emergency Medicine. Her arterial pressure was 200/110 mm Hg. Brain computed tomography (CT) revealed a 25 сm3 right-sided PICH with a minimal perifocal edema. CT angiography revealed a saccular aneurysm located in the right distal LSA with the dome of 5 mm and the neck of 2 mm. We performed right frontotemporoparietal osteoplastic craniotomy and used the transsylvian transinsular approach to PICH represented by ruptured while we were removing the blood clots. We performed aneurysm trapping and removed the hematoma.Results. This clinical case demonstrates the possibility of successful microsurgical repair of the distal lateral LSA aneurysm rupture. Six months postoperatively, the patient had complete regression of left leg paresis and partial restoration of left hand functions.Conclusion. This case report appears quite interesting since deep intracerebral hematomas of this etiology are extremely rare. An optimal treatment for LSA aneurysms remains a subject of debate due to the small number of patients with this disorder and limited data on it. Patients with fusiform aneurysms require conservative treatment and dynamic follow-up with periodic cerebral angiography. Patients with typical saccular aneurysms or PICH presenting mass effect should undergo surgical treatment.