Vessel Perforation Research Articles

Vascular Involvement in Neurosarcoidosis

Background and ObjectivesCerebrovascular manifestations in neurosarcoidosis (NS) were previously considered rare but are being increasingly recognized. We report our preliminary experience in patients with NS who underwent high-resolution vessel wall imaging (VWI).MethodsA total of 13 consecutive patients with NS underwent VWI. Images were analyzed by 2 neuroradiologists in consensus. The assessment included segment-wise evaluation of larger- and medium-sized vessels (internal carotid artery, M1-M3 middle cerebral artery; A1-A3 anterior cerebral artery; V4 segments of vertebral arteries; basilar artery; and P1-P3 posterior cerebral artery), lenticulostriate perforator vessels, and medullary and deep cerebral veins. Cortical veins were not assessed due to flow-related artifacts. Brain biopsy findings were available in 6 cases and were also reviewed.ResultsMean patient age was 54.9 years (33–71 years) with an M:F of 8:5. Mean duration between initial diagnosis and VWI study was 18 months. Overall, 9/13 (69%) patients had vascular abnormalities. Circumferential large vessel enhancement was seen in 3/13 (23%) patients, whereas perforator vessel involvement was seen in 6/13 (46%) patients. Medullary and deep vein involvement was also seen in 6/13 patients. In addition, 7/13 (54%) patients had microhemorrhages in susceptibility-weighted imaging, and 4/13 (31%) had chronic infarcts. On biopsy, 5/6 cases showed perivascular granulomas with vessel wall involvement in all 5 cases.DiscussionOur preliminary findings suggest that involvement of intracranial vascular structures may be a common finding in patients with NS and should be routinely looked for. These findings appear concordant with previously reported autopsy literature and need to be validated on a larger scale.

Vessel-preserving en-bloc excision of groin recurrence of vulval carcinoma with tensor fasciae latae flap reconstruction in a previously irradiated field

Objectives: Groin node dissection for recurrent vulval cancer in a previously irradiated field presents many surgical challenges - risk of vascular involvement, ill-defined planes and poor tissue quality for closure and healing. Our case demonstrates the feasibility of surgical management and value of flap reconstruction in managing disease relapse in such patients. Methods: We present the surgical approach to recurrent squamous cell carcinoma (SCC) vulva in a patient who has undergone previous radical radiotherapy to the site of relapse. Download : Download high-res image (268KB) Download : Download full-size image Results: In 2019 - a 70 year old lady underwent radical vulvectomy and left gluteal fold flap reconstruction, followed by radical radiotherapy and concomitant cisplatin for stage IIIc SCC vulva. A total of 12 months later, the patient presented with a clinically palpable, fixed left groin swelling. Imaging confirmed an FDG-avid 2.6 x 4.2 centimetre (cm) partially necrotic left inguinal lymph node, engulfing the femoral vessels. The patient was counselled pre-operatively by both gynae-oncology and plastic surgery – offering surgical excision of this single site recurrence, anticipating the need for further flap reconstruction for wound closure. Additional challenges included body mass index (BMI) of over 40 kilograms/metre2 and chronic candida of the abdominal pannus. Joint examination under anaesthetic by gynae-oncology and plastic surgery confirmed no vulval recurrence and no palpable right groin nodes. Left thigh perforator vessels were identified and marked using doppler. An 8.6 x 3.1cm elliptical incision was made around the fixed underlying node; and systematic inguino-femoral lymph node dissection performed using both bipolar scissors and an advanced energy device. An en-bloc specimen measuring 6.6 x 3.1 x 6.1cm was obtained. The femoral artery and vein were identified; and long saphenous vein preserved. Wound closure was achieved by raising an 18 x 8cm tensor fasciae latae (TFL) islanded flap, rotating and anchoring into place. Postoperatively, the patient was managed jointly under gynae-oncology and plastic surgery. Intravenous antibiotics, anti-fungals and thromboprophylaxis were given. The patient was advised to avoid sitting for 2 weeks. Drain outputs were monitored; and drains removed day 14. A small area of wound dehiscence occurred along the inferior border of the groin flap – which was healing well by secondary intention at the time of 4 week post-operative review, without need for further management. Final histopathology confirmed excised metastatic SCC, with a plan for ongoing surveillance arranged. Conclusions: In patients having undergone previous radiotherapy - surgery remains the main therapeutic option for recurrence. Undertaking such surgery, however, in a previously irradiated field - with altered anatomy and compromised perfusion - significantly increases the risk of inadvertent vessel or nerve injury and wound breakdown. We have demonstrated an approach, however, in an obese patient that achieved disease clearance through meticulous dissection, achieving wound closure and healing by incorporating TFL flap reconstruction.

Transcatheter Treatment of Secondary Tricuspid Regurgitation With Direct Annuloplasty: Results From a Multicenter Real-World Experience.

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The feasibility of the flower stenting technique for ostial lesions of the common iliac artery.

Background and AimsA balloon‐expandable stent (BES) is generally used for ostial lesions of the common iliac artery (CIA) owing to the positional ease of stent adjustment. However, there are potential risks such as vessel dissection and perforation due to vessel overstretching during. In our hospital, we performed endovascular therapy (EVT) for CIA ostial lesions via a novel method named “the flower stenting method,” using a self‐expandable stent. This study aimed to analyze the efficacy and safety of this method.MethodsThis study was single‐center, retrospective, and observational. We enrolled 83 patients (91 limbs) who underwent EVT with SMART stent (Cordis, Miami, Florida) for CIA ostial lesions from 2007 to 2014. The primary endpoint was the rate of freedom from target lesion revascularization (TLR) in 5 years, and the secondary endpoint was the success rate of stent placement for the CIA ostium.ResultsThe average patient age was 72.3 ± 9.4 years, 71% of the patients were men, 19% were receiving hemodialysis, and 60% had diabetes. Additionally, 38% of the lesions were Trans‐Atlantic Inter‐Society Consensus C/D lesions, while 37% were chronic total occlusion lesions. The average lesion length was 36 ± 23 mm, and the average vessel diameter was 10.7 ± 1.4 mm. The rate of freedom from TLR was 97.3% at 5 years, and the success rate of only stent placement was 90.1%.ConclusionThe flower stenting method leads to acceptable outcomes and is useful for accurate stent deployment.

Modified Volar Oblique Triangular Flap for Coverage of Fingertip Defects

Fingertip includes the portion of the digit which is distal to the insertion of flexor digitorum profundus (FDP) tendon and the extensor tendon. It is the most vulnerable part of the hand to be injured. So, reconstruction of this part requires a good outcome in sensation and function. To meet the goal of the reconstruction principle, "Like with Like" local flap is the most preferable. Such type of flap is a Volar oblique triangular flap based on volar perforator vessels from the Digital artery proper. The aim of the study is to identify its reconstruction outcome in viability, sensation, range of movement of DIPJ, and patients' satisfaction regarding contour. This was a prospective observational study; ten patients were included who were admitted in the Burn and Plastic surgery Department of Rajshahi Medical College Hospital, Rajshahi, from September 2019 to December 2020. Thirteen flaps were harvested to cover for the fingertip defect of ten patients; among them, three were female. The age range of our operated patient was 2- 38 years. None of the flaps was lost except marginal necrosis or epidermal loss. The range of movement of DIPJ and 2SPD were within the normal limit. Patients were satisfied with their contour. So, the modified volar oblique, triangular flap is one of the good options for fingertip defects.
 TAJ 2021; 34: No-1: 63-69

Intracranial Stenting: Angioplasty Basic Technique, Indications, and Sizing: 2-Dimensional Operative Video.

Intracranial atherosclerotic disease (ICAD) is a common cause of stroke. Antiplatelet therapy is the mainstay for symptomatic ICAD treatment. Endovascular management with submaximal angioplasty and/or intracranial stenting is reserved for patients with repeated ischemic events despite optimal medical therapy. We demonstrate intracranial angioplasty and stenting technique, technique indications, and sizing of stent and target vessel diameter. Stenting and angioplasty have been described in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis and Wingspan Stent System Post Market Surveillance trials.1,2 Submaximal angioplasty has also been described.3 This patient, who had been on dual antiplatelet therapy for several months, initially presented with occlusion of the left middle cerebral artery M2 inferior division and underwent mechanical thrombectomy with successful reperfusion. Postoperatively, the patient's symptoms did not improve. Medical management was optimized with heparin infusion. However, repeat stroke study demonstrated M2 inferior division reocclusion. A decision was made to proceed with intracranial angioplasty and stenting. P2Y12 levels were therapeutic. Under moderate conscious sedation, submaximal angioplasty of up to 80% of the normal M2 caliber was attempted. However, we observed persistent high-grade stenosis of the M2 inferior division. The major risk of crossing the lesion for angioplasty is vessel perforation. To safely perform this maneuver, we used a J-configured Synchro-2 microwire (Stryker). Because of the patient's recent thrombectomy, we also had prior tactile feedback about how much resistance was encountered while crossing the occlusion. We then deployed a balloon-mounted intracranial stent for optimal radial force across the stenotic area to restore perfusion. Postoperative computed tomography perfusion showed resolution of the previously noticed perfusion deficit. The patient gave informed consent for the procedures and video recording. Institutional review board approval was deemed unnecessary. Video. ©University at Buffalo Neurosurgery, September 2020. With permission.

A Practical Tip for Intraoperative Perforator Vessel Selection

In planning of free-style free perforator flaps, relying on defined anatomical landmarks and preoperative imaging technologies is difficult to locate the perforating arteries. Situation gets more complicated when encountered multiple perforating arteries enter the small skin paddle. In these situations, the ideal perforator has to be selected mostly by clinical inspection. We would like to share our method for selecting the ideal perforating vessel in free-style perforator flaps by utilizing portable thermal camera, which may be a reliable intraoperative adjunct. An index digit soft-tissue reconstruction was planned with a free posterior interosseous artery flap. Preoperatively, two perforators were marked on intermuscular septum. After the skin island is elevated totally, both of the arteries were found to be of similar by means of caliber (<0.8 mm) and pulsation. A cold challenge test was applied to flap and a continuous video record with thermal camera was taken for 1 min. Video record shows that the dominant perforator is the distal one. Thus, the flap was raised based on distal perforator. Postoperative follow-up was uneventful. The portable thermal imaging is a low cost and readily accessible intraoperative adjunct for selecting the dominant perforator in free-style perforator free flaps.

Wood Anatomy of Argophyllaceae (Asterales): Adaptation in a Small Clade

Argophyllaceae (Argophyllum, 14 spp.; Corokia, 6 spp.; Lautea, 1 sp.), are shrubs that occur in the southwestern Pacific and eastern Australia. They occur in habitats where moisture is relatively common but dry days and mild frost may occur. The woods of these genera show enough distinctive features to justify their grouping in a single family: perforation plates with 10–20 bars, vessel elements narrow and numerous per mm2, imperforate tracheary elements about 50% longer than the vessel elements, axial parenchyma scarce, diffuse, multiseriate rays narrow and heterocellular (upright cells common in uniseriate rays), crystals absent, gum deposits common. These features group the genera of Argophyllaceae more closely with each other than with the nearest families in Asterales (Alseuosmiaceae, Phellinaceae). Probable apomorphies of the genera include helical thickenings in vessels and tracheids, together with abundant tracheids and rare septate fiber-tracheids (Corokia); almost total absence of axial parenchyma and tracheids combined with maximal abundance of septate fiber-tracheids and no helical thickenings (Argophyllum, Lautea). Lautea, formerly included within Corokia, has floral and foliar distinctions and is endemic to a single island, Rapa Iti. Woods of Argophyllaceae are alike in their ecological adaptations (perforation plates, vessel diameter and density) but the presence of tracheids and helical thickenings in Corokia suggest adaptations to frost and mild drought. As expected, vessels group more prominently in the tracheid-free species (Argophyllum, Lautea) but very little in the tracheid-rich genus Corokia.

Case Report: Role of Rotational Atherectomy in Complex PCI

Background : One in three patients undergoing percutaneous coronary intervention (PCI) exhibits moderate or severe coronary artery calcification. Coronary calcification remains a major independent predictor of PCI failure and adverse outcomes. PCI of calcified coronary lesions remains challenging, despite significant improvements in the available tools and techniques. Rotational Atherectomy (RA) is a critical component to improve PCI success in these situations by producing lumen enlargement by physical removal of plaque and reduction in plaque rigidity, thus facilitating dilation Case Illustration: A 73-year-old man with exertional angina was referred to our hospital, with a history of hypertension, diabetes mellitus, ex-smoker and dyslipidemia. Physical exam, electrocardiogram, chest x-rays, and laboratory findings were unremarkable, but transthoracic echocardiogram revealed anterior wall hypokinesis. History of cardiac catheterization outside of our center with angiographic result of left anterior descending (LAD) lesion, highly calcified, non-dilatable on first several POBA attempts. Coronary angiography at our center, revealed diffuse calcification from proximal to distal of the LAD artery with about 90% maximum stenosis in mid LAD. RA (Rotablator, Boston) was then performed with A 1.50 mm burr gradually advanced at 150,000 rpm to passed the lesion. After deployments of stents, final angiogram showed well positioned stents with good distal run-off flow. The patient was uneventful during the procedure and was discharged following day. Discussion: In experienced hands, RA is as safe as standard PCI. RA is as a tool to make PCI possible in complex lesions with moderate or severe calcification when clinical variables make PCI appropriate. Rotablator is a catheter-based interventional cardiology procedure using a high-speed rotational device designed to ablate atherosclerotic plaque and restore luminal patency. This help to facilitate stent delivery, avoiding the barotrauma caused by repeated high-pressure balloon inflations that can lead to vessel dissection or perforation. Atherectomy can be performed safely with optimal burr selection and proper ablation techniques, and as a result, complication rates have been significantly minimized, with few changes in the acute complications reported in contemporary studies.

Safety and effectiveness of Phoenix atherectomy for endovascular treatment in calcified common femoral artery lesions.

Background: Traditionally endarterectomy has been considered as the gold standard technique for the treatment of common femoral artery (CFA) lesions. The aim of this study is to investigate the procedural safety and mid-term outcomes of minimal invasive Phoenix atherectomy for the treatment of CFA lesions. Patients and methods: Phoenix atherectomy was used for treatment of 61 consecutive, moderately to heavily calcified CFA lesions in 56 patients. Lesions were classified based on the CFA occlusive disease classification (Type I, II&III lesions). Primary endpoints were technical, procedural, and clinical success rate. Safety endpoints (vessel perforation, peripheral embolization) and clinically driven target lesion revascularization (TLR) were also assessed. Results: Of 61 CFA lesions, 58 (95%) exhibited at least moderate/severe calcification (PACSS3 in 38 (62%) and PACSS4 in 20 (33%) cases). Type III lesions were present in 30 (49%), type I/II lesions in 31 (51%) cases. Technical and procedural success was achieved in 30 (49%) and all 61 (100%) lesions, respectively with low complication rates (0% perforation, 2% embolization). Adjunctive treatment after atherectomy was performed using drug-coated balloon (DCB) in 35 (57%) and bail-out stenting in 6 (10%) cases. Target lesion revascularization (TLR) occurred in 4 (7%) cases during a mean follow-up duration of 11±7months. All patients exhibited clinical improvement at follow-up, showing mean Rutherford category reduction from 3.7±1.1 to 1.5±1.1 (p<0.001). Conclusions: The Phoenix device can be used for the effective endovascular treatment of CFA lesions, due to its reasonable safety profile and mid-term results.

Intravascular Lithotripsy for Calcium Modification in Chronic Total Occlusion Percutaneous Coronary Intervention.

Intravascular lithotripsy (IVL) has been shown to be safe and effective for calcium modification in nonocclusive coronary artery disease (CAD), but there are only case reports of its use in calcified chronic total occlusions (CTO). We report data from an international multicenter registry of IVL use during CTO percutaneous coronary intervention (PCI) and provide provisional data regarding its efficacy and safety. During the study period, IVL was used in 55 of 1053 (5.2%) CTO PCI procedures. IVL was used within the occluded segment after successful CTO crossing in 53 procedures and during incomplete CTO crossing in 2 cases. The mean J-CTO score was 3.1. CTO PCI technical and procedural success was achieved in 53 (96%) and 51 (93%) cases. Six patients had a procedural complication, with 3 main vessel perforations (5%). Two had covered stent implantation, one required pericardiocentesis, and one was managed conservatively. All had combination therapy with another calcium modification device. Two patients had a procedural myocardial infarction (PMI) (4%), and two others had a major adverse cardiovascular event (MACE) (4%) at a median follow-up of 13 (4–21) months. IVL can effectively facilitate calcium modification during CTO PCI. More data are required to establish the efficacy and safety of IVL and other calcium modification devices when used extraplaque or in combination during CTO PCI.

Clinical anatomy considerations on the muscular and vascular components of the midface by ultrasonographic imaging.

The first signs of face aging appear in the midface, so procedures such as botulinum toxin and filler injections are performed there. However, no guidelines based on clinical anatomy describing the muscular and vascular components in vivo have been published. The aim of this research was to describe the depths of the midface muscles and the locations of vessels using ultrasonographic (US) imaging. US was applied at 12 landmarks on the midface in 88 volunteers (49 males and 39 females; 19-36 years) to detect sex differences in the depths of muscles and the locations of the vessels. The depths of the orbicularis oculi (OOc), levator labii superioris alaeque nasi (LLSAN), and zygomaticus minor (Zmi) differed significantly with sex at P7 (p=0.001) and P8 (p=0.017), P1 (p=0.028), and P4 (p=0.035), respectively. The facial artery, facial vein, angular artery, angular vein, and perforator vessels were found at P9, P2 and P10, P1, P1 and P5, and P8, P11 and P12, respectively. The findings indicate that the depths of the OOc, LLSAN, and Zmi muscles differ between the sexes and that the vessels appear at specific landmarks. This information could help in developing anatomical guidelines for several procedures.

Under pressure: pressure-dependent pontine compression by a dolichoectasia basilar artery, a case report

Basilar artery dolichoectasia can lead to ischemic stroke through thrombosis of small perforating vessels of the brainstem. Here we report the case of a patient with transient paramedian pontine syndrome in the setting of a hypertensive crisis, finding a dolichoectasia basilar artery compressing on the ventral surface of the pons. The outcome was near-complete resolution of deficits after blood pressure control. We propose increased basilar artery pulse pressure as a novel mechanism of transient compression of the brainstem by a dolichoectasia artery.

Anatomy of the deep circumflex iliac artery perforators and reconstruction of complex mandibular defects with chimeric deep circumflex iliac artery perforator flap

To investigate the anatomy of the perforator vessels of the deep circumflex iliac artery (DCIA) and the techniques for repairing mandibular complex defect using chimeric deep circumflex iliac artery perforator flap (DCIAPF). We analyzed the origin, distribution, number and courses of the perforator vessels of the DCIA, and measured the outside diameters of the vessels at the origin in 6 adult cadaveric specimens (12 sides) with latex perfusion. From July, 2018 to September, 2019, based on the results of anatomical study and imaging findings and using the digital surgical guide plate, we harvested DCIAPF from 4 patients for repairing mandibular body or angle defects and oral soft tissue defects. The perforating vessels of the DCIA included abdominal muscular branches, osteomusculocutaneous branches and terminal musculocutaneous branches. The abdominal muscle branches originated from the DCIA inguinal segment in 4 and from both the inguinal and iliac segments in 2 of the specimens. The osteomusculocutaneous branches all originated from the internal iliac crest in 75% and from both the inguinal and internal iliac crest segments in 25% of cases; the inguinal segment gave rise to only one perforating branch. The number of the musculocutaneous perforating branches was 1 (58.3%) or 2 (41.7%). In the 4 patients undergoing mandibular reconstruction, the DCIAPF survived in all cases with good recovery of the donor site wound. Satisfactory facial appearance with good oral morphology and occlusal relationship was achieved at 1 month postoperatively in all the patients. None of the patients experienced obvious functional abnormalities at the donor site, and imaging examination confirmed successful reconstruction of the oromandibular defects in all the cases. A good understanding of the anatomic characteristics of the perforator vessels of the DCIA combined with imaging examinations and digital surgery technology facilitates the harvest of DCIAPF for repairing mandibular body or angle defects complicated by oral soft tissue defects.

Muscle-sparing rectus abdominis myocutaneous flap vascularized with intercostal artery perforator and inferior epigastric artery perforator for breast reconstruction

To explore the surgical technique, effectiveness, and safety of muscle-sparing rectus abdominis myocutaneous flap vascularized with intercostal artery perforator and inferior epigastric artery perforator for breast reconstruction. Between December 2016 and February 2019, 6 cases of early breast cancer received modified radical surgery, lower abdominal flap was applied for one- or two-staged breast reconstruction. The average age of the patients was 34.6 years (range, 29-56 years). The disease duration ranged from 2 to 16 months, with an average of 9.5 months. The tumor was located in the upper outer quadrant in 4 cases and the lower outer quadrant in 2 cases. Pathological examination showed that they were all invasive ductal carcinoma. Four cases of breast cancer were in stage Ⅰ and 2 cases was in stage Ⅱ. During operation, the inferior epigastric artery perforators were found to be close to the upper edge of the flap and/or near the umbilical cord in 4 cases, the inferior epigastric artery perforator vessels were relatively small (<0.3 mm) in 2 cases; and the breast was reconstructed with muscle-sparing rectus abdominis myocutaneous flap vascularized with intercostal artery perforator and inferior epigastric artery perforator. The length, width, and thickness of the flap were (28.9±0.2), (12.1±0.4), and (4.4±0.3) cm, respectively. The length of the vascular pedicle was (11.5±0.2) cm and the weight of the flap was (420.5±32.7) g. All 6 muscle-sparing rectus abdominis myocutaneous flaps were successful, and the breast incisions healed by first intention. There was no vascular crisis, donor site effusion, hematoma, or infection. All 6 patients were followed up 12-36 months (mean, 26.8 months). The reconstructed breast had a good shape, good elasticity, and no flap contracture or deformation; only linear scars left at the donor site of the flap, and the abdominal wall function was not affected. During follow-up, there was no breast cancer recurrence and metastasis. When the inferior epigastric artery perforators are too close to the upper edge of the flap and/or near the umbilical cord, the vascularity of lower abdominal flap can be ruined, harvested in form of muscle-sparing rectus abdominis myocutaneous flap vascularized with intercostal artery perforator and inferior epigastric artery perforator can efficiently ensure blood supply safety.

Finite element analysis of cutting balloon expansion in a calcified artery model of circular angle 180°: Effects of balloon-to-diameter ratio and number of blades facing calcification on potential calcification fracturing and perforation reduction.

Calcified artery lesions cause stent under-expansion and increase the risk of in-stent restenosis and stent thrombosis. Cutting balloons facilitate the fracturing of calcification prior to stent implantation, although vessel dissection and perforation are potential issues. In clinical practice, calcifications having maximum calcium angles ≤ 180° are rarely fractured during conventional balloon angioplasty. We hypothesize that the lesion/device diameter ratio and the number of blades facing a non-circular calcified lesion may be crucial for fracturing the calcification while avoiding vessel injury. The geometries of the cutting balloons were constructed and their finite-element models were generated by folding and wrapping the balloon model. Numerical simulations were performed for balloons with five different diameters and two types of blade directions in a 180° calcification model. The calcification expansion ability was distinctly higher when two blades faced the calcification than when one blade did. Moreover, when two blades faced the calcification model, larger maximum principal stresses were generated in the calcification even when using undersized balloons with diameters reduced by 0.25 or 0.5 mm from the reference diameter, when compared with the case where one blade faced the calcified model and a balloon of diameter equal to the reference diameter was used. When two blades faced the calcification, smaller stresses were generated in the artery adjacent to the calcification; further, the maximum stress generated in the artery model adjacent to the calcification under the rated pressure of 12 atm when employing undersized balloons was smaller than that when only one blade faced the calcification and when lesion-identical balloon diameters were used under a nominal pressure of 6 atm. Our study suggested that undersized balloons of diameters 0.25 or 0.5 mm less than the reference diameter might be effective in not only expanding the calcified lesion but also reducing the risk of dissection.

The Removal of a Fractured Guidewire During Mechanical Thrombectomy. a Case Report.

Recent randomized controlled trials have transformed the treatment of acute ischemic stroke. Mechanical or aspiration thrombectomy is the main treatment option for occlusions of large intracranial vessels. Despite its high technical success rate, endovascular thrombectomy can sometimes be complicated by anatomical peculiarities or device failures. The most frequent complications are related to vessel dissection or vessel perforation by devices while navigating intricate anatomy. Rarer still are technical device failures, like spontaneous stent-retriever detachment, which occurred with older generation retrievers. This case reports a rare device failure, which, to the best of our knowledge, has not been reported in the literature so far, namely a microwire fracture in the middle cerebral artery. This was successfully removed with an Eric stent-retriever. The potential causes and possible management strategies are discussed.

Reconstruction of soft tissue defects around the Achilles region with distally based extended peroneal artery perforator flap

IntroductionAchilles tendon rupture and soft tissue infections with wound dehiscence and tendon exposure following the tendon repair are not infrequent. Various procedures have been described for the reconstruction of soft tissue defects at the Achilles tendon region, yet there is lack of consensus on the ideal method. In this article we report our experience using the distally based peroneal artery perforator flap in reconstruction of combined defects of the Achilles tendon and overlying soft tissue. Methods7 patients with Achilles tendon injury and full-thickness soft tissue defects over the Achilles region underwent tendon repair and soft tissue reconstruction with the distally based peroneal artery perforator flap. Perforator vessels were identified at the septum between the peroneus longus and soleus muscles. After choosing the perforator with the largest diameter, meticulous deep dissection of the perforator was performed and completed 6 cm proximal to the lateral malleolus. The peroneal artery was transected and ligated and transposition of the flap to the defect was performed through a subcutaneous tunnel. ResultsThe size of the soft tissue defects and flaps ranged between 2×3 cm to 4×10 cm and 4×5 cm to 5×12 cm, respectively. Six out of 7 flaps survived completely without any complications. Post-operative venous congestion was observed in one patient which resulted in partial tip necrosis of the flap. The resulting wound healed with conservative treatment. Donor sites healed uneventfully in all patients. All flaps had excellent contour and provided stable soft tissue coverage. ConclusionDistally based peroneal artery perforator flap can be considered as a reliable alternative for the reconstruction of soft tissue defects around the Achilles tendon region. Advantages include (1) extended reach of the flap for the defects around the plantar and dorsal aspects of the foot, provided by the perforator dissection, (2) convenience with footwear and walking, provided by the skin texture similarity with the target region, (3) creating a protective surface to allow tendon gliding and prevent tissue adhesions after the tendon repair, provided by the crural fascia included in the flap, (4) obviating the need for microsurgical anastomosis and associated length of the operation.

Challenging Giant Insular Gliomas With Brain Mapping: Evaluation of Neurosurgical, Neurological, Neuropsychological, and Quality of Life Results in a Large Mono-Institutional Series.

ObjectiveGiant insular tumors are commonly not amenable to complete resection and are associated with a high postoperative morbidity rate. Transcortical approach and brain mapping techniques allow to identify peri-insular functional networks and, with neurophysiological monitoring, to reduce vascular-associated insults. Cognitive functions to be mapped are still under debate, and the analysis of the functional risk of surgery is currently limited to neurological examination. This work aimed to investigate the neurosurgical outcome (extent of resection, EOR) and functional impact of giant insular gliomas resection, focusing on neuropsychological and Quality of Life (QoL) outcomes.MethodsIn our retrospective analysis, we included all patients admitted in a five-year period with a radiological diagnosis of giant insular glioma. A transcortical approach was adopted in all cases. Resections were pursued up to functional boundaries defined intraoperatively by brain mapping techniques. We examined clinical, radiological, and intra-operative factors possibly affecting EOR and postoperative neurological, neuropsychological, and Quality of Life (QoL) outcomes.ResultsWe finally enrolled 95 patients in the analysis. Mean EOR was 92.3%. A Gross Total Resection (GTR) was obtained in 70 cases (73.7%). Five patients reported permanent morbidity (aphasia in 3, 3.2%, and superior quadrantanopia in 2, 2.1%). Suboptimal EOR associated with poor seizures control postoperatively. Extensive intraoperative mapping (inclusive of cognitive, visual, and haptic functions) decreased long-term neurological, neuropsychological, and QoL morbidity and increased EOR. Tumor infiltration of deep perforators (vessels arising either medial to lenticulostriate arteries through the anterior perforated substance or from the anterior choroidal artery) associated with a higher chance of postoperative ischemia in consonant areas, with the persistence of new-onset motor deficits 1-month post-op, and with minor EOR. Ischemic insults in eloquent sites represented the leading factor for long-term neurological and neuropsychological morbidity.ConclusionIn giant insular gliomas, the use of a transcortical approach with extensive brain mapping under awake anesthesia ensures broad insular exposure and extension of the surgical resection preserving patients’ functional integrity. The relation between tumor mass and deep perforators predicts perioperative ischemic insults, the most relevant risk factor for long-term and permanent postoperative morbidity.

Procedural Effectiveness With a Focused Force Scoring Angioplasty Catheter: Procedural and Clinical Outcomes From the Scoreflex NC Trial

BackgroundThe Scoreflex NC scoring angioplasty catheter is designed with a short rapid-exchange tip distal to a non-compliant, high-pressure balloon and an integral wire outside of the balloon, such that the guidewire and the integral wire act as scoring elements during balloon inflation. The external scoring elements enable a focal stress pattern facilitating expansion of resistant lesions at lower pressures using a focused force angioplasty effect. MethodsPatients undergoing elective percutaneous coronary intervention (PCI) were enrolled in a prospective, single-arm study conducted at 12 centers in the United States. The primary endpoint was device procedural success, defined as the composite of successful device delivery to the target lesion with balloon inflation and deflation; absence of vessel perforation, flow-limiting dissection or reduction in TIMI flow from baseline; and achievement of final TIMI 3 flow. ResultsAmong 200 patients (234 lesions), lesion complexities included: bifurcation disease (37.6%), moderate/severe calcification (36.6%), and total occlusions (5.0%). Successful delivery to the target lesion, inflation and removal of the balloon catheter was achieved in 95.5% of patients (191/200). Procedural success was achieved in 93.5% (187/200) of patients, and final TIMI 3 flow was observed in 99.0% of cases (198/200). No unanticipated device-related events occurred. In-hospital major adverse events were reported in 4.5% of patients (9/200), related to periprocedural myocardial infarction (8/200, 4.0%) and target lesion revascularization (1/200, 0.5%). ConclusionsAmong patients undergoing elective PCI and with varied lesion complexity, these results support the safety and effectiveness of a dilation strategy using the Scoreflex NC scoring catheter.