Preoperative 3D-CT Angiography Research Articles

Additional V2 behind the bronchus intermedius identified by preoperative 3D-CT angiography and bronchography.

Additional V2 behind the bronchus intermedius identified by preoperative 3D-CT angiography and bronchography.

LAPAROSCOPIC COLORECTAL SURGERY: ANALYSIS OF THE FIRST OPERATIONS

The aim of the research: to analyze the initial experience of the introduction of laparoscopic technologies in the surgical treatment of patients with colorectal cancer (CRC).
 Materials and Methods. Our experience in performing laparoscopic operations includes 7 patients (3 men and 4 women) on CRC who underwent laparoscopic operations in the Ternopil Regional Clinical Hospital from December 2021 to July 2022. The mean age of patients was 64,42 ± 10,87 (range 46-75). All patients underwent preoperative 3D-CT angiography and vascular anatomy of the mesentery. 4 patients had previously undergone surgery and had a connective tissue laparoscopic viscerolysis. In 2 patients, the tumor grew into the lateral abdominal wall, pelvic lateral wall and loop of the small intestine, respectively, combined operations were performed. D3 lymphadenectomy was performed in 2 cases and D2 lymphadenectomy was performed in 5 cases. Stapler intracorporeal anastomosis was applied to 3 patients, manual extracorporeal anastomosis was applied to 3 patients. 3 patients receive adjuvant chemotherapy. Statistical analysis was performed using Statistica 64 software. Ordinal data were calculated using the median.
 Results. The average blood loss was 120±73,7 ml (range 40-250 ml). Intraoperative time was 242,86±45,44 minutes (interval 180-300 minutes). The average number of removed lymph nodes was 16,57 ± 8, (range 12-35). According to the TNM classification, stage T1 was detected in 1 patient, T2 -2, T3 - 3, T4a - 2, T4b – 1. Three patients were diagnosed with a high (G1) degree of adenocarcinoma differentiation, 2 patients were diagnosed with a moderate (G2) degree, while a low (G3) degree was diagnosed in 2 patients. Metastasis to regional lymph nodes were detected in 3 patients. In 3 cases, the macrodrug was removed through a 4-cm Pfanenstiel incision, in 2 cases through a 5-cm incision above the umbilicus, in 1 case through access in the left mesogastric area, where a sigmoid was later formed, and in 1 case through the perineum. We did not observe any cases of anastomosis leakage or 30-day mortality. In 1 patient the postoperative period was complicated by the development of pseudomembranous colitis. R0 resection was achieved in all patients. During the laparoscopic resection of the sigmoid colon in a patient with a T1 tumor, there were difficulties in locating the tumor, the situation was resolved by intraoperative colonoscopy. In the future, we plan to use the technique of endoscopic marking with the help of special stewed paints. The treatment of 3 patients at the pre- and postoperative stages was carried out according to the fast-track protocol, respectively, the patients were discharged from the hospital 3-4 days after the operation
 Conclusions. Laparoscopic surgery is safe and feasible for colorectal cancer and has resulted in improved short-term outcomes and equivalent oncological outcomes compared with open surgery, even in the setting of colon obstruction. Good selection of patients, preoperative 3D CT-angiography and management of patients according to the program of accelerated rehabilitation are the keys to reducing postoperative complications and faster recovery of patients.

Evaluation of Lymphadenectomy Range Using Preoperative 3D-CT Angiography and Real-time Indocyanine Green Fluorescence Imaging for Lymphatic Flow in Laparoscopic Left Transverse Colon Cancer Surgery

目的：左側横行結腸癌に対する腹腔鏡下手術における術前3D-CT angiography（CTA）と術中ICG蛍光法によるリンパ流評価を駆使したリンパ節郭清範囲について検討する．

PREOPERATIVE COMPUTED TOMOGRAPHY ANGIOGRAPHY IN MULTIDISCIPLINARY PERSONALIZED ASSESSMENT OF PATIENT WITH RIGHT-SIDED COLON CANCER: SURGEON AND RADIOLOGIST POINT OF VIEW.

ABSTRACTBACKGROUND:3D-CT angiography has made it possible to reach a qualitatively new level in the determination of treatment tactics for patients with colorectal cancer.AIMS:This study aimed to analyze the clinical and radiological aspects that need to be discussed before surgery by a multidisciplinary team in patients with right-sided colon cancer.METHODSThis study involved 103 patients with colorectal cancer who underwent preoperative 3D-CT angiography from 2016 to 2021RESULTS:All patients underwent radical D3 right hemicolectomy. The median quantity of removal lymph nodes were 24.71±10.04. Anastomotic leakage was diagnosed in one patient. We have identified eight most common types of superior mesenteric artery. The ileocolic artery crossed the superior mesenteric vein on the anterior surface in 64 (62.1%) patients and on the posterior surface in 39 (37.9%). In 58 (56.3%) patients, the right colic artery was either absent or was a nonindependent branch of superior mesenteric artery. The distance from the root of the superior mesenteric artery to the root of the middle colic artery was 37.8±12.8 mm and that from the root of the middle colic artery to the root of the ileocolic artery was 29.5±15.7 mm. The trunk of Henle was above the root of the middle colic artery in 66 (64.1%) patients, at the same level with the middle colic artery in 16 (15.5%), and below the middle colic artery in 18 (17.5%) patients.CONCLUSIONS:Preoperative analysis of 3D-CT angiography is a key pattern in assessment of vascular anatomy and can potentially show the complexity of future lymphadenectomy and reduce the risk of anastomotic leakage.

Utility of preoperative three-dimensional CT bronchography and angiography in uniportal video-assisted thoracoscopic anatomical lobectomy: a retrospective propensity score-matched analysis.

BackgroundPersonalized three-dimensional (3D) reconstruction can help surgeons to overcome technical challenges and variations of pulmonary anatomic structures in the performance of uniportal video-assisted thoracoscopic surgery (UVATS), thus improving the safety and efficacy of the procedure. This study aims to evaluate the utility of preoperative 3D-CT bronchography and angiography (3D-CTBA) with Exoview software in the assessment of anatomical variations of pulmonary vessels, and to analyze short-term surgical outcomes in patients undergoing UVATS lobectomy.MethodsWe retrospectively analyzed the data of 198 consecutive patients who underwent curative UVATS lobectomy between November 2019 and September 2020. The patients were divided into an “Exoview” group (n=53) and a “non-Exoview” group (n=145). We performed 1:1 propensity score matching and compared intraoperative and postoperative outcomes between the two groups. A subgroup analysis of 74 patients who underwent single-direction uniportal lobectomy was also conducted. Aberrant pulmonary vessel patterns related to the surgery were also examined.ResultsThe operative time in the Exoview group was significantly shorter than that in the non-Exoview group, both before (145.7±33.9 vs. 159.5±41.6 minutes, P=0.032) and after (145.7±33.9 vs. 164.2±41.8 minutes, P=0.014) propensity score matching. The number of mediastinal lymph nodes dissected was higher in the Exoview group than in the non-Exoview group (8.19±6.89 vs. 5.78±3.3, P=0.024) after propensity score matching. Intraoperative blood loss showed a statistical difference between the Exoview and non-Exoview groups (60.4±45.4 vs. 100.8±83.9, P=0.009). Four types of arterial variations and 2 types of venous variations related to the surgery were observed among 8 patients (15%), which have rarely been reported before.ConclusionsPersonalized preoperative 3D-CT bronchography and angiography helped to clearly visualize the pulmonary anatomical structures and could contribute to the safe and efficient performance of UVATS anatomical lobectomy.

Laparoscopic abdominal perineal rectal resection for rectal cancer with a horseshoe kidney using preoperative 3D-CT angiography: a case report

BackgroundA horseshoe kidney is a congenital malformation involving the fusion of the bilateral kidneys and is often accompanied by anomalies of the ureteropelvic and vascular systems. When performing resection of colorectal cancer in a patient with horseshoe kidney, damage to the ureter or excessive renal arteries should be avoided. To achieve this purpose, comprehensive preoperative anatomical assessments and surgical planning are important. Here, we report a case of a laparoscopic abdominal perineal rectal resection for lower rectal cancer with a horseshoe kidney.Case presentationA 79-year-old woman presented with bloody stool and was diagnosed with advanced lower rectal cancer, immediately above the rectal dentate line, without metastasis. A preoperative computed tomography (CT) scan revealed a horseshoe kidney, while a three-dimensional CT (3D-CT) angiography revealed aberrant excess renal artery from the aorta to the renal isthmus. The left ureter ran in front of the isthmus of the horseshoe kidney and presented calculus formation. Laparoscopic abdominal perineal rectal resection was performed with D3 lymph node dissection. During the operation, we mobilized the sigmoid colon mesentery via a medial approach and preserved the left ureter, the left gonadal vessels, and the hypogastric nerve plexus in the retroperitoneum in front of the horseshoe kidney.ConclusionsWe report a rare case of rectal cancer surgery in a patient with a horseshoe kidney. We discuss the anatomical peculiarities of a horseshoe kidney, such as excess renal arteries, inferior vena cava, ureter, gonadal vessels, and nerves, that should be preserved according to the literature. We suggest that preoperative 3D-CT angiography is both useful for revealing the relationship between the vascular system and a horseshoe kidney and helpful when performing laparoscopic surgery for a left-sided colon and rectal cancer to avoid intraoperative injury.

Preoperative 3D-CT bronchography and angiography facilitates single-direction uniportal thoracoscopic anatomic lobectomy.

Competency in video-assisted thoracoscopic surgery (VATS) lobectomy is estimated to be reached after 50 cases. Preoperative identification of individualized pulmonary vascular drainage is essential for the safe and fluent performance of single-direction uniportal VATS (UVATS) anatomic lobectomy. Digital anatomy models established by three-dimensional computed tomography bronchography and angiography (3D-CTBA) is therefore utilized to accumulate variations of the right upper lobe (RUL) veins, as right upper lobectomy is considered to be the most complicated and challenging procedure. This study aims to investigate the perioperative outcomes and learning curve of single-direction UVATS RUL lobectomy assisted with 3D-CTBA. The patients who underwent single-direction intercostal UVATS anatomic RUL lobectomy after 3D-CTBA simulation by the same surgeon at Xuzhou Central Hospital between January 2017 and April 2019 were retrospectively reviewed (3D-CTBA group), and consisted of 99 males and 54 females, with a mean age of 61.6 years, with the variations of the RUL vein being assessed preoperatively. They were further divided into group A (30 cases), B (30 cases), C (30 cases), and D (63 cases), in accordance with the order of surgery. Meanwhile, the first 35 cases of single-direction UVATS RUL lobectomy by another experienced surgeon (after the learning curve of this procedure) who did not use 3D-CTBA was enrolled as a control group. The operation time, intraoperative blood loss, stations and numbers of harvested lymph nodes, the incidence of conversion to multiport VATS or thoracotomy, thoracic tube retention for drainage, complications defined under the Clavien-Dindo system, pain score, and postoperative hospital stay were analyzed. The previous surgical experience of the two surgeons was also evaluated. A significant difference was evident among the 5 groups in terms of age, smoking history, the proportion of neoadjuvant chemotherapy, and T staging of the tumors (P<0.05, respectively). As for the 3D-CTBA group, a total of 29 cases (19.0%) of anomalous RUL posterior segmental pulmonary vein (PV) (V2) drainage were recorded, while the other 124 patients indicated the central type (V2a. Cent.). Of the uncommon RUL V2, they could be further classified into 4 types [V2a. Post. (5/153, 3.3%), VX2a. Ant. (17/153, 11.1%), VXX2a. Ant. (3/153, 2.0%), and nonspecific complicated (4/153, 2.6%)]. Single-direction UVATS lobectomy was performed in every patient successfully. No perioperative mortality, major bleeding, conversion to thoracotomy, the addition of incisions, or 30-day unplanned readmission was recorded. One patient in group B reported an injury of a bronchial artery. All cases had an R0 resection. The operation time of group A (109.8±25.4 min) was significantly longer than that of group B (79.7±11.1 min), C (77.0±12.1 min), D (69.3±16.0 min), and the control (86.1±17.9 min, P<0.001 respectively). Moreover, the operation time of the patients in group B, C, and D was slightly shorter than the control, although without significance (P>0.05, respectively). Furthermore, the duration of chest tube drainage in group A (3.7±2.2 days) was noticeably longer than that in group B (3.0±0.9 days), C (2.7±1.6 days), D (2.6±0.8 days), and the control (2.7±1.6 days, P=0.004 among the groups). Similarly, postoperative hospital stay in group A (3.9±2.3 days) was noticeably longer than that in group B (3.0±1.0 days), C (2.8±1.8 days), D (2.6±0.8 days), and the control (2.8±1.8 days, P=0.002 among the groups). The 5 groups indicated comparable stations and numbers of the harvested lymph nodes, intraoperative blood loss, postoperative total chest drainage volume, incidence of complications, and pain scale on the 14th day after surgery (P>0.05, respectively). Preoperative 3D-CTBA digital anatomy facilitates the safe and fluent performance of single-direction UVATS anatomic right upper lobectomy, with a learning curve of 30 cases. High-quality trials for better evidence are called for to verify these findings.

A case of laparoscopic high anterior resection of rectosigmoid colon cancer associated with a horseshoe kidney using preoperative 3D-CT angiography

BackgroundHorseshoe kidney is a congenital malformation in which the bilateral kidneys are fused. It is frequently complicated by other congenital malformations and is often accompanied by anomalies of the ureteropelvic and vascular systems, which must be evaluated to avoid iatrogenic injury. We report a case of laparoscopic high anterior resection of rectosigmoid colon cancer associated with a horseshoe kidney using preoperative 3D-CT angiography.Case presentationA 52-year-old Japanese man with lower abdominal pain underwent lower endoscopy, revealing a type 2 lesion in the rectosigmoid colon. He was diagnosed with rectosigmoid colon cancer with multiple lung metastases and a horseshoe kidney on computed tomography (CT) scan. Three-dimensional (3D)-CT angiography showed an aberrant renal artery at the isthmus from 3 cm under the inferior mesenteric artery (IMA) branch of the aorta. Laparoscopic anterior rectal resection was performed. During the operation, the inferior mesenteric artery, left ureter, left gonadal vessels, and hypogastric nerve plexus could be seen passing over the horseshoe kidney isthmus and were preserved. The left branch of aberrant renal artery that was close to IMA was also detected and preserved.ConclusionTo prevent intraoperative misidentification, 3D-CT angiography should be performed preoperatively to ascertain the precise positional relationships between the extra renal arteries and the kidney. We always must consider anomalous locations of renal vessels, ureter, gonadal vessels, and lumbar splanchnic nerve to avoid laparoscopic iatrogenic injury in patients with a horseshoe kidney.

Anatomical thoracoscopic segmentectomy for lung cancer.

Minimally invasive surgery for lung cancer has seen considerable progress. A segmentectomy is less invasive than a lobectomy as it preserves lung parenchyma. The preservation of pulmonary function can reduce complications. The combination of a thoracoscopic approach with a segmentectomy should be less invasive, and retrospective studies have shown that the thoracoscopic approach is safe and feasible due to the lower postoperative mortality and complication rates as compared to an open thoracotomy. The validity of a segmentectomy for ground-glass-opacity-type lung cancer has been demonstrated, and it has also been evaluated for small, predominantly solid, lung cancers. Two prospective studies of segmentectomy versus lobectomy for ≤2-cm non-small-cell lung cancer are now underway (CALGB 140503 and JCOG0802/WJTOG4607L) and should clarify the role of segmentectomy. Regarding thoracoscopic segmentectomy, few retrospective studies have reported the oncological outcome for lung cancer and there is inadequate evidence regarding the long-term oncological outcome, although the perioperative complication rate and duration of hospital stay seem to be non-inferior to those of an open approach. For preoperative simulation, three-dimensional multidetector computed tomography (3D-CT) is essential for performing an atypical thoracoscopic segmentectomy safely. Preoperative 3D-CT angiography and bronchography (3D-CTAB) enable accurate identification of the venous branches in the affected segment and the intersegmental vein. This review describes the surgical and oncological outcomes, utility of 3D-CTAB, and surgical techniques and procedure used for a thoracoscopic segmentectomy.

Significance of preoperative 3D-CT angiography for localization of the femoral artery in complicated THA

BackgroundMajor vascular injury is one of the most devastating complications in total hip arthroplasty (THA). Risk for intraoperative vascular injury is increased when the normal vascular anatomy is distorted by previous surgery or dislocation with displacement. Therefore, an appreciation of the vascular anatomy in relation to the anticipated surgical field is critical to avoid this complication during preoperative assessment for a complicated THA. MethodsPreoperative three-dimensional (3D) CT angiography was performed for 24 complicated THAs when altered vascular anatomy around the acetabulum was suspected. When assessing the CT images, the presence of apparent proliferation of vessels close to the original acetabulum as well as a distance of <10 mm from the artery to the acetabulum was deemed a potential risk factor for intraoperative vascular injury. Additionally, the relationships of clinical characteristics and the presence of these risk factors were analyzed to identify the patient population at risk. ResultsThe incidence of proliferation of collateral vessels was higher in patient groups with proximal femoral migration of 5 cm or more and multiple previous surgeries prior to the index THA. Moreover, in three ankylosed hips, lateral deviation of the main vascular trunk with an artery-acetabulum distance of <10 mm was identified in all cases. ConclusionPreoperative 3D-CT angiography in cases of complicated THA revealed altered vascular anatomy which may increase the risk for intraoperative vascular injuries. Patient characteristics related to the risk for this complication were marked proximal femoral migration, multiple previous surgeries, and hip ankylosis. Preoperative image examination of the vascular anatomy is thought to help reduce the risk of inadvertent vascular injury in these complicated THA cases.

Preoperative dual-phase 3D CT angiography assessment of the right hepatic artery before gastrectomy

In the current study, we evaluated the efficacy of dual-phase three-dimensional (3D) CT angiography (CTA) in the assessment of the vascular anatomy, especially the right hepatic artery (RHA), before gastrectomy. The study initially included 714 consecutive patients being treated for gastric cancer. A dual-phase contrast-enhanced CT scan using 32-multi detector-row CT was performed for all patients. Among the 714 patients, 3D CTA clearly identified anomalies with the RHA arising from the superior mesenteric artery (SMA) in 49 cases (6.9 %). In Michels' classification type IX, the common hepatic artery (CHA) originates only from the SMA. Such cases exhibit defective anatomy for the CHA in conjunction with the celiac-splenic artery system, resulting in direct exposure of the portal vein beneath the #8a lymph node station, which was retrospectively confirmed by video in laparoscopic gastrectomy cases. Fused images of both 3D angiography and venography were obtained, and could have predicted the risk preoperatively, and the surgical finding confirmed its usefulness. Preoperative evaluations using 3D CTA can provide more accurate information about the vessel anatomy. The fused images from 3D CTA have the potential to reduce the intraoperative risks for injuries to critical vessel, such as the portal vein, during gastrectomy.

Sylvian fissure開放における工夫

Splitting of the sylvian fissure is the gateway for a neurosurgical beginner in microsurgery. Techniques for splitting the sylvian fissure have varied among neurosurgeons partly due to a paucity of objective data in the literature. We focused on the point along the sylvian fissure in the apex of the pars triangularis of the frontal operculum, where the subarachnoid space is reported to be relatively large and appears appropriate for the starting point of splitting the sylvian fissure. In practice, the distance from this point to the frontal base along the superficial sylvian fissure is compared between the data of preoperative 3D-CT angiography (3DCTA) surface images and that of the operative view. In both methods, anatomical identification of the pars triangularis and adjacent structures is almost definite except for cases presenting with subarachnoid hemorrhage. There is a significant correlation between them, indicating a favorable place to start splitting the sylvian fissure is approximately 31 mm distal from the frontal base. Moreover, the bifurcation of the middle cerebral artery was situated at the approximate bisect point in the line connecting the starting point with the frontal base. We concluded that preoperative 3DCTA surface image is a feasible and reliable method to determine the starting point of splitting the sylvian fissure. We also report the importance of epiarachnoidal dissection through a subfrontal approach combined with standard subarachnoidal splitting, especially if one wishs to safely dissect severely adhesive and interdigitated parts. In most cases, a part that is hard to split is encountered, just before the M1 segment in the sphenoidal compartment of sylvian fissure has been confirmed. This technique makes transsylvian splitting safe and promising by increasing the visualization of adhesive brain structures.

Utility of Preoperative 3D CT Angiography and Proximal Balloon Occlusion to Minimize Morbidity of Open Repair of a True Subclavian Artery Aneurysm

This report highlights the utility of three dimensional (3D)-CT angiography, in conjunction with combined endovascular and open surgical management, to treat a degenerative subclavian artery aneurysm. The patient presented with an incidentally discovered right subclavian artery aneurysm and underwent surgical reconstruction without complication. Although a variety of case reports in the literature document repair of various subclavian artery pathologies including those associated with aberrant subclavian artery anatomy (Kommerel's diverticulum), iatrogenic pseudoaneurysm, and thoracic outlet compression with post-stenotic dilatation, post-inflammatory and infectious aneurysms; true fusiform degenerative aneurysms of the subclavian artery remain a rare clinical entity. These lesions present with variable anatomic configurations, which can be clearly defined with pre-operative CT or MR angiography. Defining the anatomy with 3D imaging can facilitate clinical decision- making and allow potential application of hybrid approaches to surgical management.

Short-term outcome in living donors for lung transplantation: the role of preoperative computer tomographic evaluations of fissures and vascular anatomy

Successful living-donor lobar lung transplantation (LDLLT) largely depends on donor outcome. We reviewed our experiences with LDLLT and focused on preoperative computed tomographic evaluations of donors. Twenty-five LDLLTs were performed in Kyoto University. As a routine preoperative assessment, high-resolution chest computed tomography (CT), and three-dimensional (3D)-CT angiography were performed. Preoperative evaluations, surgical procedures, and early postoperative outcomes were reviewed in 43 consecutive LDLLT donors. All donors were discharged home after the donor lobectomies. Severely incomplete fissures were intraoperatively identified in two donors, whose interlobar fissures were mostly not identified by high resolution CT preoperatively. Preoperative 3D-CT angiography was effective for the identification of the branches of the pulmonary artery and vein. Pulmonary arterioplasties were performed with auto pericardial patches in three left donors. The bilateral donors had to be exchanged because of an anomaly of the pulmonary veins in one donor. Small pulmonary arterial branches to the remaining lobes were to be sacrificed in 23 donors (53%). Early postoperative complications were ascertained in seven donors, and five of them presented air leak-related complications. Living donor lobectomies were safely performed with low morbidities in our institution. Preoperative computer tomographic evaluations might be useful in donor lobectomies.

肺区域切除における術前CTアンギオグラフィー

肺区域切除術を安全かつ円滑に遂行する上で，術前に肺血管の分岐を把握することは重要であり，我々は3DCTが有用であることを報告してきた．一回撮像によるCTを用いる場合，動静脈のコントラストが明瞭であることが望まれる．造影CTで通常行われていた（A法）と当院で工夫した生理食塩水を後押しする方法（B法）を後ろ向きに検討した．対象は2008年1月～2009年11月までに，胸腔鏡下区域切除を行った22例．うちわけはA法が10例，B法が12例であった．3DCT画像における肺動静脈区別が良好例および不良例はA法で1例：9例，B法で9例：3例であった（p=0.002）．肺動脈と左房におけるCT値の測定で，その較差はA法で22.1, B法で106.6であり，B法が有意に肺動静脈の濃度差が大きかった（p=0.002）．一回撮像法による造影CTにおいて，B法は肺動静脈の区別描出に有用であった．

Unique variation of the hepatic artery identified on preoperative three-dimensional computed tomography angiography in surgery for gastric cancer: Report of a case

Hepatic artery injury is one complication associated with surgery for gastric cancer. This complication does not occur frequently, but it can cause serious problems. Anatomical variations of the hepatic arteries are thought to be a factor in such injuries. Recognizing vascular variations before the operation is thus very important. This report presents a case with a rare variation of the hepatic arteries identified on three-dimensional computed tomography (3D-CT) angiography before gastric cancer surgery. Hepatic artery injury was avoided as a result of the recognition of this extremely rare variation. Preoperative 3D-CT angiography is useful for preventing the complications associated with hepatic artery injury during surgery for gastric cancer.

Preoperative assessment of the pulmonary artery by three-dimensional computed tomography before video-assisted thoracic surgery lobectomy

Our aim was to evaluate the efficacy of 3D imaging using multidetector row helical computed tomography (MDCT) in the preoperative assessment of the branching pattern of pulmonary artery (PA) before complete video-assisted thoracoscopic lobectomy (complete VATS lobectomy) for lung cancer. Forty-nine consecutive patients with clinical stage I lung cancer scheduled for complete VATS lobectomy were evaluated about branching pattern of PA on 16-channel MDCT. Intraoperative finding of the PA branching pattern were compared with the 3D-CT angiography images obtained using MDCT. According to the intraoperative findings, 95.2% (139 of 146) of PA branches were precisely identified on preoperative 3D-CT angiography. All of the seven undetected branches were within 2mm in diameter. There was not a case that needed conversion to open thoracotomy because of intraoperative bleeding. A 3D-CT angiography using MDCT clearly revealed individual anatomies of pulmonary artery and could play an important role in safely facilitating complete VATS lobectomy procedure. However, we were unable to detect several thin branches with this technique. So, more care should be taken to avoid bleeding from these small vessels.

A Classification of Unruptured Middle Cerebral Artery Bifurcation Aneurysms that can Help in Choice of Clipping Technique

Middle cerebral artery (MCA) aneurysms comprise 20-25% of all intracranial aneurysms. The majority of middle cerebral artery aneurysms are treated by microsurgical clipping. Most of the classifications of aneurysms at present are based on size, location or pathology which are effective for the description but are less useful in preoperative planning and also in deciding on the technique or type of clip application. The aim of our study was to examine the morphological features of unruptured MCA bifurcation aneurysms which influence the techniques of clipping of these aneurysms and to attempt to subclassify unruptured middle cerebral artery aneurysms based on their preoperative 3D CTA and intraoperative characteristics so as to help in the intraoperative choice of technique and clip application, respectively. Preoperative 3D CT angiography and intraoperative images along with the record of technique and type of clips used for 141 unruptured MCA aneurysms operated at our center were studied retrospectively. Unruptured MCA bifurcation aneurysms could be subclassified into 5 types based on the similarities in their morphological features which influenced the techniques of clipping as recorded from their preoperative 3D CTA and intraoperative view. These types and the distinctive feature of each type are described. The various techniques of clipping are discussed based on these subgroups. The groups outlined make possible the establishment of a common technical approach to clipping within the groups. This classification, based on preoperative 3D CTA and intraoperative morphological features of the aneurysm and parent vessels, helps in the intraoperative choice of technique and type of clip application to tackle these lesions.

3D CT angiography of abdominal wall vascular perforators to plan DIEAP flaps

Since the first report of TRAM flap reconstruction, there have been numerous studies to reduce complications of elective breast reconstruction. Current methods of preoperative perforator localization can be time-consuming, inaccurate, and imprecise. Thus, we sought to evaluate ultra-high resolution 3D CT angiography for the preoperative mapping of DIEAP flap perforating vessels. We reviewed all perforator-based breast reconstructions performed over a 5-month period. Candidates for DIEAP flap reconstruction were sent for a focused CT scan of the abdominal wall, using the 64 slice multi-detector CT scanner. This article presents our first 23 flaps in 17 patients with preoperative ultra-high resolution 3D CT angiography. The reconstruction plan changed in three patients (18%). There was one take-back for venous congestion, but no partial or total flap loss. Preoperative perforator flap planning for breast reconstruction utilizing 3D CT angiogram is safe, easy to read, and can change the operative plan.