Neck Hematoma Research Articles

Results of robot-assisted minimally invasive esophagectomy in 111 consecutive patients: an Asia cohort study

BackgroundRobot-assisted minimally invasive esophagectomy (RAMIE) is becoming increasingly popular as a treatment for esophageal cancer. The purpose of this study was to use the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA, USA) to perform 111 consecutive cases of radical esophageal cancer and report the perioperative data of surgery and postoperative complications and short-term oncological outcomes.MethodsWe retrospectively analyzed 111 patients who underwent RAMIE conducted at Fujian Medical University Union Hospital from August 2016 to January 2021. Each patient’s characteristics, clinicopathological stage, postoperative pathological stage, surgery outcome, postoperative recovery, and short-term oncological outcomes were analyzed.ResultsOf the 111 patients who underwent RAMIE, 77 were male and 34 were female, and the mean age was 62.1 ± 8.8 years. Twenty-seven patients (24.3%) received preoperative neoadjuvant therapies, the most popular of which was preoperative induction chemotherapy in 16 cases (14.4%), followed by preoperative induction radiotherapy in 8 cases (7.2%) and preoperative induction chemotherapy plus immunization in 3 cases (2.7%). The vast majority of patients (110/111, 99.1%) underwent radical resection, with a mean intraoperative bleeding amount of 99.9 ± 68.4 mL and a mean operative time of 271.9 ± 70.0 min. The mean total number of lymph nodes removed was 40.9 ± 16.7, including 21.8 ± 9.0 thoracic lymph nodes. Fifty-five (49.6%) patients had lymph node metastases, including 17 (15.3%) with lymph node metastases in the left recurrent laryngeal nerve, 24 (21.6%) with lymph node metastases in the right recurrent laryngeal nerve, and 7 (6.3%) with lymph node metastases in the bilateral recurrent laryngeal nerve. The positive rate of left recurrent nerve lymph nodes was 4.77%, and he positive rate of right recurrent nerve lymph nodes was 8.38%. The main postoperative complications included pulmonary infection in 24 cases (21.6%), celiac disease in 3 cases (2.7%), tracheoesophageal fistula in 1 case (0.9%), anastomotic fistula in 3 cases (2.7%), postoperative cardiac arrhythmias in 11 cases (9.9%), VTE in 3 cases (2.7%), and pleural effusion (requiring postoperative tube drainage) in 13 cases (11.7%). Additionally, 2 cases of postoperative pneumothorax (1.8%), 1 case of poor incision healing (0.9%), 1 case of incomplete bowel obstruction (0.9%), 1 case of neck hematoma (0.9%), and 1 case of postoperative admission to the intensive care unit (0.9%) occurred. The median length of stay was 10.9 ± 6.1 days, and there were no cases of perioperative death.ConclusionsRobotic esophageal cancer radical surgery is safe and feasible. The surgeon can be proficient in thoracic robotic surgery and mediastinal lymph node dissection and achieve high levels of perioperative safety and short-term efficacy.

Complications of Thyroid Cancer Surgery in Pediatric Patients at a Tertiary Cancer Center.

The incidence of complications and risk factors for hypocalcemia after pediatric thyroid cancer surgery has not been clearly defined in the literature because most reports fail to distinguish between benign and malignant disease. The trend away from total thyroidectomy (TT) to thyroid lobectomy in low-risk disease means there is a need to clearly define the complication profile of malignant disease. After institutional review board (IRB) approval, a retrospective chart review was undertaken at Memorial Sloan Kettering Cancer Center for pediatric patients undergoing surgery for well-differentiated thyroid cancer from 1986 to 2021. Clinicopathologic characteristics and complications were evaluated. Multivariable analysis was performed to identify factors independently associated with postoperative hypocalcemia. The study identified 307 pediatric patients with well-differentiated thyroid carcinoma (median follow-up period, 61 months). Of these patients, 69% underwent TT and 31% received a partial thyroidectomy. Among them, 40% had N0 disease, 28% had N1a disease, and 33% had N1b disease. Postoperatively, no patients experienced a neck hematoma, 1.6% had temporary unilateral vocal cord palsy (VCP), and 0.7% had permanent VCP due to recurrent laryngeal nerve (RLN) invasion. Temporary and permanent hypocalcemia occurred in respectively 32.6 % and 5.2 % of the patients. Multivariable analysis identified central neck dissection (CND) (odds ratio [OR] 3.30; p < 0.001) and N1 disease (OR 2.51; p = 0.036) as independent risk factors for temporary hypocalcemia and N stage (OR 3.64; p = 0.018) as a risk factor for permanent hypocalcemia. Pediatric thyroid cancer surgery results in low complication rates despite nodal metastases. Vocal cord paralysis is rare unless disease is found to be invading the RLN intraoperatively. Both N stage and CND are independent risk factors for hypocalcemia, helping to identify high-risk patients.

Endovascular revascularization of chronically occluded common carotid artery for symptomatic cerebral hypoperfusion.

Endovascular recanalization is increasingly being utilized in symptomatic patients with chronically occluded carotid arteries.1 In carefully selected patients, endovascular recanalization has shown to lower the risk of ischemic events when compared to medical management alone.1 However, successful endovascular revascularization is technically challenging and not without risk.1, 2 In this video, we demonstrate a case of a 64-year-old woman who presented with recurrent transient ischemic attacks. On imaging she was found to have a chronic total occlusion of the common carotid artery from the arch. After obtaining informed consent, the patient underwent a successful endovascular recanalization and stenting of a chronically occluded left common carotid artery with aid from an intravascular guided re-entry catheter. Post operatively the patient developed a neck hematoma which improved and she returned to her neurological baseline. She reported no further symptoms on her three month follow up.

Quality of Life and Postoperative Outcomes After Surgery in Carotid Body Tumor Patients

The aim of this study was to study the quality of life (QoL) and postoperative outcomes in patients with carotid body tumor (CBT) undergoing surgery. This was an observational study in a tertiary care center in North India. A total of 18 patients with CBT undergoing surgery were included. All patients were operated upon by a vascular surgeon at the center. The patient demographics, disease characteristics, intraoperative data, and postoperative outcomes were recorded. All patients were followed for a period of ≥3 months following surgery. The QoL was assessed using the European Organization for Research and the Treatment of Cancer (EORTC) questionnaires. The EORTC QLQ-30 was used to assess global health and functional health status, whereas the EORTC H&N-35 was used to assess symptomatic health. The QoL data were recorded preoperatively for all patients, whereas 11 patients agreed to provide postoperative QoL data using physical and telephonic follow-ups. The preoperative and postoperative QoL data were compared. Among 18 patients, 11 (61%) were female and 7 (39%) were male. The median age of patients was 35 years (range, 21-62 years). The median duration of symptoms at presentation was 3.5 years (range, 0.17-13 years). The Shamblin grade was I in one (5%), II in 12 (67%), and III in five (28%) patients. The disease was bilateral in two (11%) patients. A family history of CBT was present in one (5%) patient. The size of the tumor ranged from 3 to 10 cm. Of all the patients, two patients (11%) underwent preoperative angioembolization. All patients underwent CBT excision. The mean operative time was 2.7 ± 1.0 hours. The mean blood loss was 230 ± 232 mL. Vascular reconstruction was required in three patients (17%). Nerve resection was required in two patients (11%). Both patients had tumor sizes of >7 cm. Iatrogenic nerve injury occurred in one patient (5%). Postoperatively, one patient (5%) developed neck hematoma, which required re-exploration. The median hospital stay was 3 days (range, 1-17 days). The median follow-up was 34.5 months (range, 3-56 months). The neurological deficits were present in five patients (28%) at discharge and three patients (17%) at ≥3 months follow-up (Table I). No recurrences were observed. The change in QoL was non-significant (P > .05) in global health, functional health, and symptomatic health at ≥3 months follow-up. Surgery is an effective modality for the treatment of CBT; however, it does not affect the QoL significantly.TableNeurological deficits in patients with carotid body tumor (CBT) after surgeryDeficitAt dischargeAt ≥3 months follow-upHoarseness of voice5 (28)3 (17)Horner syndrome2 (11)0 (0)Dysphagia1 (5)1 (5)Tongue deviation2 (11)1 (5)Facial deviation1 (5)0 (0)Data are presented as number (%). Open table in a new tab

Early postoperative outcome after carotid artery endarterectomy with bifurcation advancement.

Background: The aim of this study is to review the single center experience in surgical treatment of carotid artery disease (CAD) using bifurcation advancement carotid endarterectomy (BA-CEA) and compare the in-hospital outcome with one of the largest nationwide carotid endarterectomy (CEA) databases worldwide, the German statutory quality assurance database (GD). Patients and methods: Data of BA-CEA procedures in the period of 2006-2015 were analyzed retrospectively. The primary endpoint was defined as combined stroke and death rate. Secondarily, isolated stroke, TIA, patient death, myocardial infarction, major neck hematoma and cranial nerve injuries were analyzed. Symptomatic and asymptomatic CAD patients were divided into two subgroups. The results were compared to extracted published data from the German database (GD). Results: Of 239 included BA-CEA procedures188 (78.7%) procedures were carried out in patients with symptomatic carotid artery stenosis. The overall perioperative combined stroke and death rate after BA-CEA was 2.5%.Five (2.1%) patients suffered from a stroke (one minor and four major strokes), of which two hemorrhagic strokes ended fatally. Overall, four (1.7%) patients died perioperatively. The combined stroke and death rate was higher in the symptomatic subgroup (3.2%; 0% in the asymptomatic group). No significant differences were found between the results of BA-CEA and the German database (n=142'074) for combined stroke and death rates and isolated stroke. Significant differences were found among the overall mortality rate (BA-CEA: 1.7% vs. GD: 0.6, p=0.04). The risk of postoperative cranial nerve injuries was also significantly higher after BA-CEA overall (BA-CEA: 5.0% vs. GD: 1.2%, p=<0.0001), in symptomatic CAD patients (BA-CEA: 4.8% vs. GD: 1.2%, p=<0.0001) and in asymptomatic CAD patients (BA-CEA: 5.9% vs. GD: 1.3%, p=0.01). Conclusions: CEA with bifurcation advancement provides comparable perioperative results, focusing on combined stroke and mortality, but seems to have some technical drawbacks, which may lead to more frequent local neurological complications.

Subtotal Thyroidectomy Postoperative Complications with Unplanned Thyroid Surgery

Background: The surgical treatment for bilateral multinodular nontoxic goiter (BMNG) is still debatable. Avoiding RLN harm during thyroid surgery if the pathology is not identified. Reduce the incidence of hypoparathyroidism by reducing the rate of parathyroid gland damage during excision. Objective: To see the complications of subtotal thyroidectomy in random thyroid surgery. Materials and Methods: This was a prospective, observational study conducted in the Department of ENT &amp; Head- Neck surgery, Rangamati Medical College, Rangamati for a period of 2 years from January 2019 and December 2020. Total 100 patients were operated for benign and malignant thyroid disorders. This study was done to assess complications after various types of thyroid surgeries indicated for benign as well as malignant thyroid lesions. Results: Ten (10.0%) patients had transient hypocalcemia followed by 4(4.0%) had transient recurrent nerve palsy, 1(1.0%) had permanent hypocalcemia, 1(1.0%) had permanent recurrent nerve palsy and 1(1.0%) had neck hematoma. Mean weight of the resected thyroid was found 62.4±14.1 gram in euthyroidism group and 74.2±26.4 gram in hypothyroidism group. Mean proportion of weight of the thyroid remnant in total weight of the thyroid was found 5.1±2.2 percent in euthyroidism group and 3.9±2.1 percent in hypothyroidism group. Conclusion: Transient hypocalcemia, transient recurrent nerve palsy, chronic hypocalcemia, permanent recurrent nerve palsy, and neck hematoma were the most frequent postoperative complications.

Outcome and Evaluation of the Patient Thyroidectomy with Hyperthyroidism: A Case-Control Study

Introduction: According to reports, pediatric patients with hypothyroidism have a higher risk of complications following surgery than adults. Specifically, this Study's aimed to evaluate how complete thyroidectomy is in youth (18 years) and adults. Materials and Methods: A retrospective case-control study of all (n=100) complete thyroidectomies was performed on 32 pediatric and 68 adult patients who were consecutive from were compared at the Department of ENT, Head &amp; Neck Surgery, Islami Bank Medical College and multicentral base hospital, Rajshahi, Bangladesh, from July 2018 to June 2021. Results: The average patient age in children was 9.7 years (range 3.4-17.9 years) against 44.9 years (range 18.4-84.2 years) in adults. Compared to adults, surgical procedures on children took an average of (2.18 ± 0.08 hrs.) longer to complete in adults (1.66 ± 0.03 hrs) (p = 0.003). The average weight of a thyroid specimen was 48.0 ± 6.4 grams in adults and 38.6.0 ± 8.9 grams in children (range, 6.6-203 grams; p = 0.34). Children had a higher ratio of thyroid weight to body weight (0.94 ± 0.11 gm/kg) than adults (0.67 ± 0.8 gm/kg; p = 0.05). After surgery, the hyperthyroid condition improved in every patient. There were no operational deaths, recurrences, or long-term hypoparathyroidism. Conclusion: It is clear that the technical difficulties associated with treating Graves' disease surgically in children and adults result in longer operational periods. There was no difference in the chances of long-term consequences, including recurrent laryngeal nerve damage or neck hematoma. Medicine Today 2023 Vol.35(1): 40-43

Increased Risk of Complications Associated With Concurrent Parathyroidectomy in Patients Undergoing Total Thyroidectomy

IntroductionWe sought to investigate the association of concurrent parathyroidectomy (PTX) with risks of total thyroidectomy (TTX) through analysis of Collaborative Endocrine Surgery Quality Improvement Program data. TTXis a common operation with complications including recurrent laryngeal nerve injury, neck hematoma, and hypoparathyroidism. A subset of patients undergoing thyroidectomy undergoes planned concurrent PTX for treatment of primary hyperparathyroidism. There are limited data on the risk profile of TTX with concurrent PTX (TTX + PTX). MethodsWe queried the Collaborative Endocrine Surgery Quality Improvement Program database for patients who underwent TTX or TTX + PTX from January 2014 through April 2020. Multivariable logistic regression was performed to predict hypoparathyroidism, vocal cord dysfunction, neck hematoma, and postoperative emergency department visit. Covariates included patient demographics, patient body mass index, indication for surgery, central neck dissection, anticoagulation use, and surgeon volume. ResultsThirteen thousand six hundred forty seven patients underwent TTX and 654 patients underwent TTX + PTX. Unadjusted rates of hypoparathyroidism were higher in TTX + PTX patients at 30 d (9.6% versus 7.4%, P = 0.04) and 6 mo (7.9% versus 3.1%, P < 0.001). On multivariable regression, TTX + PTX was associated with an increased risk of hypoparathyroidism at 30 d (odds ratio [OR] 2.09, 95% confidence interval [CI] 1.57-2.79) and 6 mo (OR 4.63, 95% CI 3.06-7.00) and an increased risk of postoperative emergency department visit (OR 1.66, 95% CI 1.20-2.31). TTX + PTX was not associated with recurrent laryngeal nerve injury or neck hematoma. ConclusionsConcurrent PTX in patients undergoing TTX is associated with increased risk of immediate and long-term hypoparathyroidism, which should be considered in informed consent discussions and operative decision-making.

Factors That Influence the Occurrence of Acute Postoperative Complications after Carotid Endarterectomy

Abstract Background This study aimed to identify early postoperative complications after carotid endarterectomy and the factors that may influence their occurrence. Methods This was an observational, analytical, prospective study conducted over a period of 3 years in 2 university hospitals in Târgu Mureș, Romania. One hundred nineteen patients who underwent carotid endarterectomy for severe carotid stenosis were included. Statistical analysis was used to identify the independent factors with a direct influence on the acute complications in the first 48 h after carotid endarterectomy. Results We followed up on the acute postoperative complications occurring in the first 2 days after surgery. These were represented by a limited number of neurological complications and major neck hematomas. Among all comorbidities and risk factors, only advanced coronary artery disease (p = 0.05) and smoking (p = 0.03) were independent factors that directly influenced the occurrence of major neck hematomas. Operative time exceeding the median time of 90 minutes increased the risk of neurological complications (p = 0.02). The risk of major neck hematomas was also increased by preoperative treatment with anticoagulants (p = 0.01) and anticoagulants associated with antiplatelet therapy (p = 0.009). Conclusions This study has identified factors such as advanced coronary artery disease, smoking, operative time, and anticoagulant therapy that may be independently associated with an increased risk of acute postoperative complications after carotid endarterectomy.

Abstract Number ‐ 174: Direct carotid puncture for mechanical thrombectomy in acute ischaemic stroke

Introduction While the benefit of mechanical thrombectomy (MT) for patients with acute ischemic stroke with large‐vessel occlusion (AIS‐LVO) has been clearly established, difficult vascular access may make the intervention impossible or unduly prolonge. In the following cases, functional and safety outcomes of mechanical thrombectomy via direct carotid puncture were evaluated in patients with acute ischemic stroke with limited vascular access. Methods We evaluated seven patients with AIS‐LVO who underwent attempted MT in last year with limmited vascular access for aborted MT after failed transfemoral access or attempted MT via DCP. Results Of 11 patients with AIS‐LVO who underwent attempted MT, Direct carotid access was successfully obtained in all patients, mean age [± SD] 63 ±15 years. Successful reperfusion (thrombolysis in cerebral infarction score 2b or 3) was achieved in 11 patients (100%). Carotid access complications included disection vascular in 1 pacient, with second vascular Access (carotid puncture) required. In 3 patients (42.8%) thrombolysis therapy with IV r‐TPA were administered during thrombectomy by direct carotid puncture. 3 patients presented neck hematomas but they did not require any subsequent interventions. All patients required angio‐seal vascular closure device for direct carotid Access 6F. We found that the final functional outcome was based on modified Rankin Scale score between 1 and 3 achieve in 8 of 11 patients (71.4%). Conclusions DCP for emergency MT in patients with AIS‐LVO and prohibitive vascular access is safe and effective and is associated with higher recanalization rates.

Efficiency of electrical welding of soft tissues during thyroid gland operations

Annotation. The purpose of the study was to study the results of using electro welding of tissues during operations on the thyroid gland in benign (nodular and multinodular goiter) and malignant (differentiated carcinoma) pathological conditions. Electric welding was ensured due to the formation of coagulum between the branches of the clamp during the action of short-duration pulses of radio frequency (440 kHz) current with a maximum power of 300 W when using a device manufactured in Ukraine by LLC “Swarmed” with the patented technology “Biowelding TM”. The results of surgical treatment of 183 patients who underwent hemi thyroidectomy (8.7%), thyroidectomy (61.2%), and thyroidectomy with dissection of the 6th collector of the neck (30%) for nodular goiter, multinodular goiter, and differentiated thyroid carcinoma, respectively, were analyzed. The use of electric welding made it possible to reduce skin incisions on the neck during surgical access (the average length of the incision was 3.77±0.02 cm). Unilateral temporary paresis of the larynx was recorded in 2 (1.1%) patients, temporary hypoparathyroidism in 3 (1.6%) patients. Bleeding, neck hematomas and wound seroma did not occur in the postoperative period. Electric welding provides reliable hemostasis, which allows you to avoid the use of other means for ligation of vessels (threads, metal clips). The average length of stay of patients in the hospital was 1.1±0.01 days.

Abstract No. 595 Endovascular Recanalization and Reconstruction for the Treatment of Symptomatic Venous Ligation

To report techniques, adverse events, and outcomes of endovascular recanalization and stent reconstruction for symptomatic venous ligation. Nine patients, including six (66.7%) men and three (33.3%) women, with mean age 52.9 ± 11.9 years (range, 35-69 years), underwent endovenous recanalization and stent reconstruction for symptomatic venous ligation over eight years. Five (55.6%), one (11.1%), and three (33.3%) patients presented with CEAP 3, 4, and 5 diseases, respectively. External iliac vein ligation occurred in six (66.7%) patients. Ligations were unilateral left, unilateral right, and bilateral in three (33.3%), four (44.4%), and two (22.2%) patients, respectively. Ligation etiologies included surgical injury in four (44.4%), traumatic injury in two (22.2%), chronic lower extremity venous thrombosis in two (22.2%), and malignant resection in one (11.1%) patient. Technical successes, reconstruction parameters, adverse events, hospital stay lengths, clinical outcomes, stent patencies, follow-up evaluations, and mortalities were recorded. Primary single-session recanalization was achieved in nine (100%) patients. Sharp, extravascular, techniques were required in 6 (66.7%) patients. Reconstructions were created with Wallstents, SMART stents, and cTAG devices. Mean number of stents was 2.9 ± 2.5 stents (range, 1-7 stents). Mean stent diameter was 15.5 ± 3.2-mm (range, 12-26-mm). Adverse events (AEs), according to the Society of Interventional Radiology, included one (10.0%) common iliac vein injury (major AE; class D) and one (7.7%) of neck hematoma (minor AE; class A). Mean hospitalization stay length was 1.6 ± 1.6 days (range, 1-6 days). Clinical improvement was achieved in eight (88.9%) patients with six (66.7%) patients downgraded to CEAP 0 disease. Eight (88.9%) reconstructions remained patent with a mean imaging follow-up of 466.4 ± 500.3 days (range, 17-1,400 days). One (9.1%) reconstruction became occluded within sixty days and was unable to be recanalized. Mean total follow-up was 1,086.2 ± 717.5 days (range, 47-2,707 days). Thirty day and study mortality were both zero. Endovenous recanalization and reconstruction is an effective and safe treatment for symptomatic venous ligation.

An analysis from the CAPACITY database of outcomes of preoperative embolization before carotid body tumor surgery compared with resection alone

ObjectiveThere is no definitive consensus on the impact of preoperative embolization on carotid body tumor (CBT) treatment. The objective of this study was to compare surgical outcomes of patients who underwent preoperative embolization before CBT resection vs patients who underwent resection alone. MethodsThe CAPACITY registry included 1432 patients with CBT from 11 medical centers in four different countries. The group of patients undergoing CBT resection with preoperative embolization was matched in a 1:6 ratio from a pool of patients from the CAPACITY database, using a generated propensity score with patients who did not underwent preoperative embolization. ResultsA total of 553 patients were included for analysis. Mean patient age was 56.23 ± 12.22 years. Patients were mostly female (n = 469; 84.8%). Bilateral CBT was registered in 60 patients (10.8%). Seventy-nine patients (14.3%) underwent preoperative embolization. Embolized patients had larger CBT sizes than non-embolized patients (33.8 mm vs 18.4 mm; P = .0001). Operative blood loss was lower in the embolized group compared with the non-embolized group (200 mL vs 250 mL; P = .031). Hematomas were more frequent in the non-embolized group (0% vs 2.7%; P = .044). Operative time, rates of stroke, cranial nerve injuries, and death were not statistically significant between groups. ConclusionsEmbolization before CBT resection was associated with significantly lower blood loss and lower neck hematomas than patients who underwent resection alone. Operative time, stroke, cranial nerve injuries, and death were similar between groups.

Post-traumatic acute aortic regurgitation due to cusp rupture in non-calcific bicuspid valve treated with ballon-expandable transcatheter heart valve.

A 65-year-old male truck driver was admitted to the emergency department after a road crush with consequent polytrauma. Patient’s past medical and cardiovascular history were unremarkable. Physical examination showed neck haematoma with multiple contusions, abolished right vesicular murmur, bone deformities. Whole-body CT scan documented multiple bone fractures, right hemothorax and pneumothorax, mediastinal haematoma, bilateral pulmonary contusions and rib fractures, dissection not limiting flow of right subclavian artery, left vertebral artery and both internal carotid arteries with associated pseudoaneurysms. Emergency chest drainage was performed and the patient was intubated because of worsening dyspnoea. Transthoracic echocardiography documented massive aortic insufficiency due to cusp rupture (Panels A and B and Supplementary material online, Videos S1 and S2) in the context of aortic bicuspidia (Sievers Type 1) and pulmonary hypertension with signs of right ventricular dysfunction. Because of patient’s extremely critical condition with hemodynamic instability and pulmonary congestion and concomitant prohibitive surgical risk for urgent aortic valve replacement, off-label transcatheter aortic valve replacement was planned.

Editor's Choice – Nationwide Outcome Analysis of Primary Carotid Endarterectomy in Symptomatic Patients Depending on Closure Technique and Patch Type

Current European guidelines recommend both eversion carotid endarterectomy (CEA) and conventional CEA with routine patch closure, rather than routine primary closure. Polyester and polytetrafluoroethylene (PTFE) have been used as patch material for a long time. More recently, bovine pericardium has been used; however, there are few studies comparing long term results between bovine pericardium and other patch types. The aim of this study was to investigate the short and long term results after CEA depending on surgical technique and patch material. A registry based study on all primary CEAs (n= 9 205) performed for symptomatic carotid artery stenosis in Sweden from July 2008 to December 2019, cross linked with data from the Swedish stroke registry, Riksstroke, and chart review for evaluation of any events occurring during follow up. The primary endpoint was ipsilateral stroke < 30 days. Secondary endpoints included re-operations due to neck haematoma and < 30 day ipsilateral stroke, > 30 day ipsilateral stroke, all stroke > 30 days, and all cause mortality. 2 495 patients underwent eversion CEA and 6 710 conventional CEA for symptomatic carotid stenosis. The most commonly used patch material was Dacron (n= 3 921), followed by PTFE (n= 588) and bovine pericardium (n= 413). A total of 1 788 patients underwent conventional CEA with primary closure. Two hundred and seventy-three patients (3.0%) had a stroke < 30 days. Primary closure was associated with an increased risk of ipsilateral stroke and stroke or death <30 days: odds ratio 1.7 (95% confidence interval [CI] 1.2 - 2.4, p= .002); and 1.5 (95% CI 1.2 - 2.0), respectively. During follow up (median 4.2 years), 592 patients had any form of stroke and 1 492 died. There was no significant difference in long term risk of ipsilateral stroke, all stroke, or death depending on surgical technique or patch material. There was an increased risk of ipsilateral stroke < 30 days in patients operated on with primary closure compared with eversion CEA and patch angioplasty. There was no difference between primary closure, different patch types, or eversion after the peri-operative phase.

A Novel Simulation Model for Training Emergency Medicine Residents in the Ultrasound Identification of Landmarks for Cricothyrotomy.

Objectives The objective of this study is to describe a simple, replicable method to create neck models for the purpose of education and practice of ultrasound (US) identification of anatomic landmarks for cricothyrotomy. The second objective is to assess the model's capability in training emergency medicine (EM) residents in the US identification of anatomic landmarks for cricothyrotomy. Methods This is a cross-sectional study using a convenience sample of EM residents. Participants were taught to identify the thyroid cartilage, the cricothyroid membrane (CTM), and the cricoid cartilage using US. After aninstructional period, participants performed a US examination ongel models designed to overly a live, human neck simulating various scenarios: thin neck, thick neck, anterior neck hematoma, and subcutaneous emphysema. Residents wereasked to identify the thyroid cartilage, the CTM, and the cricoid cartilage as quickly as possible. The mean time to successful identification was reported in seconds. Following the scanning session, participants were asked to complete a post-survey. After the session, the video recordings were reviewed by an emergency US fellowship-trained physician to assess the visuomotor skills of each participant. Results A total of 42 residents participated in the study. Ninety-three percent (32/42; 95% CI 80.3% - 98.2%) of residents were able to obtain an optimal sagittal or parasagittal sonographic view of the anterior airway landmarks. Of these residents, 21.4% (9/42; 95% CI 11.5% - 36.2%) required minimal assistance with the initial probe placement. The visuomotor scores were recorded for each participant. Results of the pearson correlation indicated that there was a significant positive relationship between the residents' year in training with their visuomotor score (r(40) = .41,p= .007). When scanning the thin neck, 90.5% (38/42; 95% CI 77.4% - 96.8%) of residents were able to successfully identify the landmarks. The median time to completion was 27 seconds. When scanning the subcutaneous air model, 88.1% (37/42; 95% CI 74.5% - 95.3%) of residents were able to successfully identify the landmarks. The median time to completion was 26 seconds. When scanning the neck with the fluid collection 95.2% (40/42; 95% CI 83.4% - 99.5%) of residents were able to successfully identify the landmarks with a median time of 20 seconds for identification. When scanning the thick neck model, 73.8% (31/42; 95% CI 58.8% - 84.8%) of residents were able to successfully identify the landmarks taking a median time of 26 seconds. After the training session, 76.2% of residents reported that they felt either "confident" or "extremely confident" in identifying the CTM using US. Conclusion The novel anterior neck gel models used in this study were found to be adequate for training EM residents in the US identification of anterior neck anatomy. Residents were successfully trained in identifying the important anterior neck landmarks that are useful when predicting a difficult anterior airway and planning for surgical cricothyrotomy. Residents overall felt thatthe models simulated the appropriate anatomic scenarios. The majority felt confident in identifying the CTM using US.

The Medial Sural Artery Perforator Free Flap: A Novel, yet Challenging and Versatile Flap for Head and Neck Reconstruction.

Background In head and neck reconstruction, especially after cancer ablation, choosing the best flap is critical. Due to its thin, lengthy, and malleable vascular pedicle as well as low donor site morbidity, the medial sural artery perforator (MSAP) free flap is gaining popularity among reconstructive surgeons, particularly in oral soft-tissue reconstructions. The goal of this study was to record the clinical use of an MSAP flap in the repair of post-oncologic lesions in the head and neck region. Methodology Patients with oral cancer who came to our center after ablative surgery on the buccal mucosa, tongue, floor of the mouth, and hard palate were repaired utilizing the MSAP flap. Preoperatively, the perforators were discovered using an 8 MHz portable doppler and a computed tomography angiogram. Without the use of a tourniquet, the flaps were delineated and harvested. In all of our patients, a single venous anastomosis was sufficient. Results The MSAP flap was used to positively rebuild 14 cancer patients, with the flap design based on the amount of the resection site or defect. The buccal mucosa (n = 7) and tongue (n = 6) were the most common subsites of the ablative defect. The average flap size was 12 × 6 cm, with a thickness of 5-7 mm. In eight cases, the donor site defect was mostly closed, with the remaining patients receiving split-thickness grafts for subsequent healing. In 12 cases, the best cosmetic and functional results were obtained. One patient developed a postoperative wound infection, and the flap could not be saved. Another patient developed a neck hematoma which had to be debrided on the second postoperative day, with good results. In primary closure cases, patients were mobilized with full weight-bearing on the first postoperative day. Conclusions MSAP flap is an alternative to radial forearm free flap and anterolateral thigh flap in obese patients with medium-sized oral abnormalities. This flap stands out as an outstanding option for head and neck soft-tissue reconstruction due to its unique mix of flap thinness, greater skin region, and superior donor site cosmesis. Despite its importance, just a few case studies and reports have been published. A multicenter trial with a high sample size would demonstrate the use of this flap and its chimeric designs.

Evaluating the Safety of Transcarotid Artery Revascularization under Local Anesthesia Prior to Coronary Artery Bypass Grafting Surgery

Controversy exists regarding the timing of intervention for patients with critical coronary artery disease awaiting coronary artery bypass and severe carotid artery stenosis. Transcarotid artery revascularization (TCAR) is a minimally invasive revascularization alternative through direct transcervical carotid access that minimizes the chance of arch manipulation and consequent antegrade embolic stroke rate. While the TCAR procedure can be performed under local anesthesia (monitored anesthesia care, MAC) vs general anesthesia, the hemodynamic benefits of local anesthesia in patients with severe CAD are significant. Patients receiving staged TCAR-CABG have high-risk cardiovascular disease and require accurate perioperative neurological and hemodynamic evaluation that can be safely provided with local anesthesia. In this retrospective single-center study, 14 patients were systematically identified to have undergone staged TCAR prior to CABG surgery from December 2018 to October 2021. All patients underwent TCAR with local anesthesia and minimal sedation. Relevant patient demographics, medical and surgical history, preoperative covariates, and type of anesthesia administered were obtained from patients' charts. Carotid artery disease was confirmed by either carotid duplex imaging or computed tomography angiography (CTA) of the head/neck. Staged TCAR-CABG interventions were performed on 14 patients (64% male; mean age 65.0 years). No major adverse cardiac events were reported including transient ischemic attack (TIA), stroke, myocardial infarction, or TCAR-related death in the interval between their TCAR and CABG as well as in a 12-month follow-up period. One patient required to return to the operating room (OR) for evacuation of a neck hematoma. This study demonstrated high success rate of TCAR under local anesthesia prior to CABG (100%) with no incidence of perioperative stroke, myocardial infarction (MI), or death at 1-month, 6-month, and 12-month follow-up intervals. The authors support the use of staged TCAR-CABG with local anesthesia as a safe and promising treatment option for patients with high-grade cardiac disease, high risk of stroke, or multiple comorbidities that preclude a CEA.

Endovascular transmural access to carotid artery perivascular tissues: safety assessment of a novel technique

BackgroundRecent advances in endovascular devices have allowed access and targeting of perivascular tissues of the peripheral circulation. The perivascular tissues of the cervical and cranial circulations have many important structures...

Transcarotid artery revascularization can safely be performed with regional anesthesia and no intensive care unit stay

ObjectiveHospital resource use is under constant review, and the extent and intensity of postoperative care requirements for vascular surgical procedures is particularly relevant in the setting of the coronavirus disease 2019 pandemic and its impact on staffed intensive care unit (ICU) beds. We sought to evaluate the feasibility of regional anesthesia (RA) and low-intensity postoperative care for patients undergoing transcarotid artery revascularization (TCAR) at our institution. MethodsAll patients undergoing TCAR at a single institution from 2018 to 2020 were reviewed. Perioperative management (anticoagulation and antiplatelet therapy, hemodynamic monitoring, neurovascular examination, nursing instructions) was standardized by use of an institutional protocol. Anesthetic modality was at the surgeon’s preference. Patients were transferred to a postanesthesia care unit for 2 hours followed by the step-down unit, to a postanesthesia care unit for 4 hours followed by the floor, or alternatively transferred to the ICU. Intravenous (IV) blood pressure medications could be administered at all environments except the floor. Recovery location and length of stay were recorded. ResultsA total of 83 patients underwent TCAR during the study period. The mean age 72 ± 9 years and 59% were male. Thirty-six percent were symptomatic. RA was used for 84% with none converted to general anesthesia (GA) intraoperatively. Postoperatively, 7 of the 83 patients (8%) included in this study were monitored in an ICU overnight (decided perioperatively), mostly for patients with prior neurological symptoms, but in 1 case for postoperative neurological event and in another owing to pulseless electrical activity arrest. Six patients required IV antihypertensives and eight required IV vasoactive support postoperatively. The mean length of ICU stay was 3.7 ± 5.1 days. The mean length of hospital stay for all patients was 2.4 ± 3.3 days. The length of stay for patients undergoing TCAR with GA was higher than those undergoing TCAR with RA (4.2 ± 4.9 days vs 1.4 ± 1.2 days, respectively; P = .066). The incidence of stroke, death, and myocardial infarction was 2.4%. There was one postoperative stroke considered to be a recrudescence of prior stroke, and one respiratory arrest fatality in a frail patient with neck hematoma both of whom were treated under GA. ConclusionsUsing perioperative care protocols, TCAR can safely be performed while avoiding both GA and an ICU stay in most patients.