Preoperative Vascular Imaging Research Articles

Suture Packaging as a Marker for Intraoperative Image Alignment in Augmented Reality on Mobile Devices.

Preoperative vascular imaging has become standard practice in the planning of microsurgical breast reconstruction. Currently, translating perforator locations from radiological findings to a patient's abdomen is often not easy or intuitive. Techniques using three-dimensional printing or patient-specific guides have been introduced to superimpose anatomy onto the abdomen for reference. Augmented and mixed reality is currently actively investigated for perforator mapping by superimposing virtual models directly onto the patient. Most techniques have found only limited adoption due to complexity and price. Additionally, a critical step is aligning virtual models to patients. We propose repurposing suture packaging as an image tracking marker. Tracking markers allow quick and easy alignment of virtual models to the individual patient's anatomy. Current techniques are often complicated or expensive and limit intraoperative use of augmented reality models. Suture packs are sterile, readily available, and can be used to align abdominal models on the patients. Using an iPad, the augmented reality models automatically align in the correct position by using a suture pack as a tracking marker. Given the ubiquity of iPads, the combination of these devices with readily available suture packs will predictably lower the barrier to entry and utilization of this technology. Here, our workflow is presented along with its intraoperative utilization. Additionally, we investigated the accuracy of this technology.

Second and Third Kidney Transplants.

Renal transplant is the best procedure for patients with end-stage renal disease. Although an ideal kidney transplant should survive for the lifetime of each recipient, there may be a need for a second, third, or even a fourth retransplant. The outcomes of these kidney allografts, surgical approaches, immunology issues, and drug therapies warrant greater focus. Pediatric kidney retransplant is even more important because these patients are more immunologically responsive to donor antigens and because they need longer allograft survival. Although kidney retransplant provides a survival advantage for patients who would otherwise remain on the wait list and/or hemodialysis, careful patient selection is crucial for second, third, and fourth renal transplants. Despite the shortage of donor organs, outcomes, manageable complications, and economic considerations support earlier kidney retransplants rather than delayed retransplants. Preoperative vascular imaging, appropriate induction therapy, regular monitoring of renal function, and regular surveillance for malignancy and infection are more important in the retransplanted kidneys than in cases of first kidney transplants. The lack of robust data on optimal clinical management of these retransplant recipients has contributed to substantial variations in clinical practice among different centers. In this review, we discuss medical and surgical approaches in the cases of second and third kidney transplants.

Optical-visualized photoacoustic tomographic navigation

The current preoperative vascular imaging methods cannot achieve noninvasive high-resolution imaging of deep-localized vessels. Photoacoustic tomography (PAT) can show microvessels with centimeter depth and submillimeter diameter without the use of contrast agents. Combined with PAT and optical projection technology, the Hessian-matrix-based skin removal algorithm and the target matching method were developed to spatially align the photoacoustic data of subcutaneous blood vessels with the anatomy of real patients and to realize three-dimensional (3D) visualization of blood vessels from the body surface. The optical projection navigation system based on PAT has high spatial resolution (∼135 μm) and temporal resolution (0.1 s). In the rabbit injection experiment, 3D distributions of needle and blood vessel (>100 μm) were obtained by image segmentation, which proved that the method can guide micro plastic injection. Furthermore, healthy volunteers' forehead imaging experiments show that 3D visualization and cross-sectional images of the human forehead clearly show the vascular network and ability of the system to image submillimeter blood vessels with penetration depth (∼10.2 mm). Our work confirms that the method of integrated photoacoustic imaging and optical projection has great potential for noninvasive diagnosis and treatment of clinical blood vessels, opening a path for the application of photonics in medical esthetics.

Vascular anomalies in patients with growth hormone-secreting pituitary adenomas: illustrative case report and systematic review of the literature

PurposeEndonasal resection is the first-line treatment for patients harboring growth hormone (GH)-secreting pituitary adenomas. The complexity of the parasellar neurovascular structures makes pre-operative diagnostic imaging essential to understanding the anatomy of this region. We aimed to describe vascular anomalies in acromegalic patients and emphasize their relevance for surgery and preoperative planning.MethodsA systematic review following the PRISMA statement was performed in July 2021.ResultsThirty-three studies were evaluated. Elevated GH and insulin-like growth factor-1 (IGF-1) levels are linked to the occurrence of cardiovascular risk factors. This is attributed to endothelial dysfunction, mainly caused by changes in flow-mediated dilatation (FMD), which is probably the main cause of vascular anomalies in acromegaly. The occurrence of protrusions of the internal carotid artery (ICA) (35–53%), a narrow intercarotid distance, and an asymmetrical course was described. In 13–18% of acromegalic patients, the presence of an intracerebral aneurysm could be reported (incidence in the general population:0.8–1.3%). The selected studies were however performed with a small patient sample (range:1–257).We present a case report of a 57y/o male patient with anomalies of the ICA (“kissing carotid arteries”) harboring a GH-secreting adenoma, which was resected via an endoscopic endonasal approach.ConclusionsThere is an association between acromegaly and endothelial dysfunction, which increases cardiovascular risk factors and vascular anomalies. Preoperative vascular imaging, e.g., CT angiography, should be implemented as a standard to identify patients at risk and estimate surgical morbidity. However, no evidence-based recommendations exist so far, so future studies are necessary.

Single-stage Congenital Polysyndactyly Release: Outcomes and Long-term Followup.

The current surgical strategy for syndactyly is multistage operations in which every other web is released, leaving adjacent webs unoperated for the next stage to avoid a presumed possible digital vascular compromise. In this series, we present our experience with single-stage multiple syndactylies release. A total of 7 patients, including 2 patients with bilateral hand involvement, were included. Dorsal and volar triangular flaps were created for commissure reconstruction, and zigzag manner volar and dorsal incisions were made to release the webbed fingers. Sterile thermoplastic splints were molded directly over the skin grafts without any dressing or tie-over. Following the surgical operation, minimal flexion contracture was seen in three patients that needed future correction procedures. Cosmesis and functional outcome were acceptable. This study shows that the release of all webs in 1 setting can be accomplished by no vascular compromise, and there is no need for a preoperative vascular imaging study.

Association of Preoperative Vascular Wall Imaging Patterns and Surgical Outcomes in Patients With Unruptured Intracranial Saccular Aneurysms.

MR vascular wall imaging (VWI) may have prognostic value in patients with unruptured intracranial aneurysms (UIAs). To evaluate the value of VWI as a predictor of surgical outcome in patients with UIAs. This prospective cohort study evaluated surgical outcomes in consecutive patients with UIAs who underwent surgical clipping at a single center. All participants underwent high-resolution VWI and were followed for at least 6 months. The primary clinical outcome was modified Rankin scale (mRS) score 6 months after surgery. The number of patients in the no wall enhancement, uniform wall enhancement (UWE), and focal wall enhancement (FWE) groups was 37, 145, and 154, respectively. Incidence of postoperative complications was 15.5% in the FWE group, 12.4% in the UWE group, and 5.4% in the no wall enhancement group. The proportion of patients with mRS score >2 at the 6-month follow-up was significantly higher in the FWE group than in the UWE group (14.3% vs 6.9%; P = .0389). In the multivariate analysis, FWE (odds ratio, 2.573; 95% CI 1.001-6.612) and positive proximal artery remodeling (odds ratio, 10.56; 95% CI 2.237-49.83) were independent predictors of mRS score >2 at the 6-month follow-up. Preoperative VWI can improve the surgeon's understanding of aneurysm pathological structure. Type of aneurysmal wall enhancement on VWI is associated with clinical outcome and incidence of salvage anastomosis and surgical complications.

FlapMap Visual Language System for Vascular Imaging Prior to Microvascular Free Tissue Transfer.

Summary:Preoperative vascular imaging has been shown to be beneficial before free tissue transfer procedures, especially for deep inferior epigastric perforator flap breast reconstruction. Although computerized tomography angiography and magnetic resonance angiogram are increasingly frequently performed, there is no standardized method for recording, analyzing, and communicating the vast amount of clinically relevant information that is obtained from these tomographic imaging studies. Herein, the authors propose a new visual language system for preoperative imaging called “FlapMap,” which allows for the creation of a clinically actionable, easily understood, and easily communicated single image that aids in preoperative planning before microvascular free tissue transfer.

Sporadic supratentorial hemangioblastoma with meningeal affection: A case report and literature review.

Background: Hemangioblastomas are vascular tumors, of benign behavior, that originate in the central nervous system. Supratentorial hemangioblastomas are extremely rare and are generally associated with Von Hippel-Lindau disease (VHL). The involvement of structures by contiguity, such as blood vessels or meninges, is something exceptional. There are few references in the literature of supratentorial hemangioblastomas with meningeal involvement and most of them are described in reports or small case series.Methods: We performed a systematic review of the literature to observe the characteristics of patients with supratentorial hemangioblastomas with meningeal involvement. In addition, we present the case of a 43-year-old male patient with a sporadic supratentorial hemangioblastoma with both, meningeal and vascular involvement that recurred years after treatment.Results: The patients presented supratentorial tumors with meningeal involvement, we had a 1.2:1 ratio male-female distribution. The mean age was 50 years. Most tumors were located in the cerebral hemispheres, the lobe affected most frequently was the frontal lobe. About 67% of the cases were sporadic and only 21% were related to VHL disease. There were three cases of recurrence after surgery.Conclusion: Supratentorial hemangioblastomas are extremely rare lesions. It is rare for supratentorial hemangioblastomas to invade adjacent structures such as blood vessels or meninges, however, when this happens, it is recommended a preoperative vascular imaging study, especially in parasagittal hemangioblastomas where superior longitudinal sinus may be involved. In these cases, en bloc surgical resection is difficult and the probability of recurrence is higher. Although clinical trials and studies with a greater casuistry are necessary to establish guidelines for the management of supratentorial hemangioblastomas, nowadays, contribution of new cases is useful for understanding this pathology.

Subarachnoid Hemorrhage as a Consequence of Pleomorphic Xanthoastrocytoma: A Case Report

Abstract BACKGROUND AND IMPORTANCE Pleomorphic xanthoastrocytoma (PXA) is a rare World Health Organization (WHO) grade II lesion considered to portend a good prognosis. However, the literature contains several references of serious intracranial hemorrhages associated with PXAs, although the etiology is poorly understood. CLINICAL PRESENTATION We present the case of a young woman with a Hunt and Hess V, Fisher 4 subarachnoid hemorrhage associated with a right cavernous sinus PXA. The case provides rare baseline angiographic imaging prior to a presenting hemorrhagic event and reveals progressive loss of structural vascular integrity at proximal large vessels. CONCLUSION This case provides insight into the natural history of this entity, tropism for catastrophic vascular injury, and informs surgical management with an emphasis on preoperative vascular imaging and preparation for proximal vascular control with cervical exposure.

Use of O-arm With Intraoperative Arteriography for Localization and Stealth Navigation of the Vertebral Arteries During Posterior Cervical Spine Surgery.

Vertebral artery injury (VAI) can be a devastating complication during cervical spine surgery. Although considered a rare occurrence overall, incidences of VAI have been reported in the ranges of 0.07% to 8%. Such injuries have the potential for catastrophic consequences, including blood loss, permanent morbid neurologic injury, and even death. The introduction of intraoperative navigation using either preoperative or intraoperative imaging has now been widely adopted in current practice so as to try and minimize adverse outcomes while giving real-time, dynamic information of the operative field. The use of the O-arm Surgical Imaging System during cervical spine surgery allows one to obtain high-resolution, accurate intraoperative imaging, and when used in concert with forms of intraoperative navigation, it can help with instrumentation and safety. However, patients undergoing cervical spine surgery do not routinely undergo preoperative vascular imaging, particularly with regard to anterior cervical or posterior high-cervical surgeries, where the incidence of VAI, in comparison with other cervical surgeries, has been reported to be the highest. Here we present the use of intraoperative O-arm-based arteriography for integration with navigation for vertebral artery localization during C1 to C3 posterior instrumentation and fusion of an unstable C2 fracture in a 54-year-old man. The patient did not experience any intraoperative VAI and was subsequently discharged with no focal neurologic deficits. Detailed in our report is our protocol and procedure for obtaining and using intraoperative angiographic images. Case report detailing O arm for intraoperative identification of vertebral arteries during C1-C3 posterior instrumentation and fusion with pre-operative unilateral vertebral artery injury.

A single centre experience of arteriovenous fistula creation for hemodialysis access in Dar es Salaam, Tanzania

Chronic kidney disease (CKD) is increasingly diagnosed and thus more patients are in need of hemodialysis (HD) to sustain their life. The quality of vascular access for HD should be suitable for repeated puncture and allow a fast blood flow rate for high-efficiency dialysis with minimal complications. Our study aimed to document local experience and early outcomes after arteriovenous fistula (AVF) creation for hemodialysis access including complications related to AVF creation.This was a hospital based clinical audit in which case notes of patients who had undergone AVF creation between May, 2017 and March, 2018 at Muhimbili National Hospital (MNH) were reviewed using a structured data collection tool. Information regarding preoperative assessment for AVF creation, outcome of AVF, and age of the patients were collected. Descriptive statistics were prepared and summarized as tables. A total of 57 case notes of patients who underwent AVF creation for HD access with males contributing majority of patients (77.2%) were reviewed. The predominant age group was 41 to 60 years of age (56.2%) with mean age 47 years and age range of 18 -69 years. Three patients had procedure abandoned on the table due to sclerotic vein. The functional maturation rate was found to be 64.9% and post AVF complications in 15 patients (26.3%). Recorded post AVF creation complications were fistula stenosis/revision (27.8%), bleeding/haematoma (22.2%), limb oedema (22.2%), aneurysm (11.1%), surgical site infection [SSI] (11.1%) and thrombus formation (5.6%).AVF creation for HD access is common at MNH with a functional maturation rate of 64.9%, which is an acceptable rate. The preoperative vascular assessment in this survey was mainly found to be physical examination while preoperative vascular imaging was not commonly done to assess suitability of veins and arteries for AVF creation although post AVF complications are relatively few.

Fibula free flap with type IIIB popliteal artery branching: a case report and recommendations

Planning for fibula free flap (FFF) reconstruction generally involves preoperative vascular imaging by computed tomographic angiography, magnetic resonance angiography or digital subtraction angiography to identify congenital variants or acquired pathology that contraindicate flap harvest. Two cases of successful FFF without ischaemic donor site morbidity in legs with type IIIB popliteal artery branching and no cases of unsuccessful harvest exist in the literature, suggesting the safety of harvesting a fibula free flap in these cases. We present a case where attempted FFF harvest in a leg with known type IIIB popliteal artery branching was aborted due to intraoperative evidence of inadequate peripheral perfusion measured by great toe pulse oximetry. There are no recommendations for additional testing to determine safety of FFF harvest in legs with type IIIB anatomy, with most authors considering this a contraindication to raising a FFF. We recommend preoperative functional testing by balloon angiography to assess the adequacy of collateral circulation where harvest of FFF is considered in legs with type IIIB popliteal branching. Level of evidence: Level V, therapeutic study.

Use of Preoperative Cervical Vascular Imaging in Patients With Velocardiofacial Syndrome and Velopharyngeal Dysfunction in the United Kingdom

In patients with velocardiofacial syndrome (VCFS), medial displacement of the internal carotid arteries (ICAs) may increase the risk of vascular injury during the surgical correction of velopharyngeal dysfunction (VPD). Some surgeons advocate the use of vascular imaging studies prior to surgery. Nevertheless, the role of preoperative imaging is still controversial. This study aimed to review the current practice of the UK cleft units and also examine our own practice at the Evelina London Children's Hospital in relation to children with VCFS undergoing speech surgery over the previous 7 years. A questionnaire was sent to all UK cleft surgeons to enquire about the management and use of preoperative vascular imaging in patients with VPD and VCFS. A retrospective study was also conducted of the unit's 7-year series of patients with VPD and VCFS. Thirty-four completed questionnaires were returned (response rate 100%). Most UK surgeons (73.5%) do not regularly order preoperative vascular imaging for patients with VCFS although some reportedly would consider it if a posterior pharyngeal wall pulsation was visible. In our unit, between 2013 and 2019, a total of 40 patients affected by VCFS have been assessed for VPD. A magnetic resonance angiography (MRA) was performed for 23 patients. Medial deviation of the ICAs was identified in 7 (30%) patients. The results of the national survey showed no consensus on routine use of preoperative vascular imaging. Our retrospective study showed a 30% prevalence of medialized ICAs in our patient cohort. In these patients, the MRA findings influenced the choice of speech surgery.

Anastomotic Technique and Preoperative Imaging in Microsurgical Lower-Extremity Reconstruction: A Single-Surgeon Experience.

The need for preoperative imaging as well as anastomotic technique (ie, end-to-side [ETS] vs end-to-end [ETE]) are areas of controversy in microsurgical lower-extremity reconstruction. The objective of this study was to (1) investigate whether preoperative imaging is mandatory and (2) to elicit if the type of anastomosis impacts clinical outcomes. A retrospective review of all patients who underwent microvascular lower-extremity reconstruction between 2007 and 2015 by a single surgeon was performed. Patients were categorized into groups based on anastomotic technique, that is, ETE versus ETS anastomosis. Patients in the ETE group were further subclassified into those who had preoperative imaging (computed tomography angiography [CTA]+) versus those who did not (CTA-). Parameters of interest included flap type, thrombosis rate, flap loss, length of stay (LOS), return to ambulation, and rate of secondary amputation. Two-sided statistical analysis was performed using Kruskal-Wallis rank-sum test and Fisher exact test. One hundred twenty-eight patients were analyzed: ETE (n = 40) and ETS (n = 88). Mean follow-up for both groups was 20 ± 19 months. Anterolateral thigh flaps were most commonly performed (71%). Overall flap loss rate was 3.1% without any significant differences noted with respect to thrombosis (arterial, P = 0.09; venous, P = 0.56), flap loss (P = 0.33), LOS (P = 0.28), amputation (P = 1.00), or return to ambulation (P = 0.77). Furthermore, the availability of preoperative imaging (CTA+: N = 11 vs CTA-: N = 29) did not impact rates of thrombosis (arterial, P = 0.29; venous, P = 0.31), flap loss (P = 1.00), LOS (P = 0.26), or return to mobility (P = 0.62). In light of similar reconstructive outcomes, we prefer to preserve distal extremity perfusion via ETS anastomoses whenever possible. Furthermore, preoperative vascular imaging angiography might not be necessary in patients with palpable pedal pulses on preoperative examination. An actionable algorithm for determining ETS versus ETE anastomosis in lower-extremity reconstruction is presented.

Unusual Venous Drainage Of The Common Facial Vein. A Morphologycal Study

Background: Anatomical knowledge of the facial vasculature is crucial not only for anatomists but also for oral and maxillofacial surgery, plastic surgeon, otorhinolaryngologists. Access pathways, pedicled and free flap transfer, and explantation and transplantation of total faces are based on the proper assessment and use of the facial veins and arteries. The anatomical variations reported in the present study confirms the need for preoperative vascular imaging for sure good venous outflow for the free flap survival.
 Aims: The aim of the present study was to describe a rare anatomical variation of the common facial vein which not been previously described.
 Methods and Findings: Head and neck region were carefully dissected as per standard dissection procedure, studied serially during the years 2013-2017 in 15 males and 2 females, i.e. 34 sides, embalmed adults cadavers with different age group, in the laboratory of Morphology of the University of Pamplona. In 33 sides (97 %) of the cases the anterior facial vein (FV) terminated into the internal jugular vein via the common facial vein (CFV) as per standard anatomic description. The right common facial vein in one side (3%) was found to drain into the contralateral internal thoracic vein and contralateral pericardiophrenic vein. Remarkable communications with the external jugular vein, the internal jugular vein, the anterior jugular vein, and left brachiocephalic vein. The length of the right common facial vein from the level of its formation till its termination in the contralateral pericardiophrenic and internal thoracic vein was about 22.75 cm. The venous drainage pattern on the left side of the face was found to be normal. 
 Conclusion: The existence of this anatomical variation among others supposes a double edge sword in the medical practice with its own opportunities and risks, especially in the surgical treatment; therefore, we need to study with more strictness these possibilities with the aim of facilitate this practices, and improve the life quality of our patients.

A High Origin Subscapular Trunk and its Clinical Implications

Important variations in the arrangement of branches of the axillary artery revolve around the of the subscapular artery. The case of a origin subscapular artery as a common trunk to lateral thoracic, common circumflex humeral trunk in the left upper limb of a 72 year-old female cadaver, is discussed. This variant trunk originated posterior to the pectoralis minor muscle about 2-3 cm posteroinferior to that of the thoracoaromial artery. Trunk formations in the axillary artery with four or more branches sharing a common stem of are infrequent compared with those with fewer numbers. In certain surgical orthopedic procedures, surgeons sometimes administer a ligature in the 3rd part of the artery, relying on a suprascapular/dorsal scapular-circumflex scapular colateral pathway to dump blood into the artery distal to the ligature. Surgeons engaged in placing such ligature should be aware of proximal of the subscapular artery, as in the case of high of the artery being presented to guide placements of such ligature. Incorrect ligature placement distal to the of the subscapular artery would result in blood being dumped proximal to the clamped site, resulting in posible ischemia, gangrene and limb loss. Preoperative vascular imaging is advocated during surgical interventions in the shoulder region to assist in the selection of appropriate procedure to help needed in the reduction of iatrogenic complications and in assisting radiologists in the correct interpretation of images.

Accuracy of intracranial electrode placement for stereoencephalography: A systematic review and meta-analysis.

Stereoencephalography (SEEG) is a procedure in which electrodes are inserted into the brain to help define the epileptogenic zone. This is performed prior to definitive epilepsy surgery in patients with drug-resistant focal epilepsy when noninvasive data are inconclusive. The main risk of the procedure is hemorrhage, which occurs in 1-2% of patients. This may result from inaccurate electrode placement or a planned electrode damaging a blood vessel that was not detected on the preoperative vascular imaging. Proposed techniques include the use of a stereotactic frame, frameless image guidance systems, robotic guidance systems, and customized patient-specific fixtures. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a structured search of the PubMed, Embase, and Cochrane databases identified studies that involve the following: (1) SEEG placement as part of the presurgical workup in patients with (2) drug-resistant focal epilepsy for which (3) accuracy data have been provided. Three hundred twenty-six publications were retrieved, of which 293 were screened following removal of duplicate and non-English-language studies. Following application of the inclusion and exclusion criteria, 15 studies were included in the qualitative and quantitative synthesis of the meta-analysis. Accuracies for SEEG electrode implantations have been combined using a random-effects analysis and stratified by technique. The published literature regarding accuracy of SEEG implantation techniques is limited. There are no prospective controlled clinical trials comparing different SEEG implantation techniques. Significant systematic heterogeneity exists between the identified studies, preventing any meaningful comparison between techniques. The recent introduction of robotic trajectory guidance systems has been suggested to provide a more accurate method of implantation, but supporting evidence is limited to class 3 only. It is important that new techniques are compared to the previous "gold-standard" through well-designed and methodologically sound studies before they are introduced into widespread clinical practice.

Detailed vascular anatomy of the medial femoral condyle and the significance of its use as a free flap

The aim of this study is to provide detailed information on the arterial variations of the descending geniculate artery (DGA) for the harvest of a cortico-periostal flap from the medial femoral condyle and a fascio-cutaneous perforator flap with its respective pedicles. A total of 50 lower limbs from embalmed cadavers were dissected. The distribution pattern, length, and diameter of the DGA, saphenous artery (SA), muscular, periostal, and articular branches, and their concomitant veins were measured and evaluated. The DGA was present in 98% of the cases. In 80%, a Y-shaped distribution was identified where the SA branched from the DGA. Here, the mean lengths of DGA, SA, and the articular branch of the DGA were 3.2±1.1, 7.18±3.2, and 6.72±2.07cm, respectively. In 18%, an H-shaped distribution was noted, where the SA emerged directly from the femoral artery with a length of 10.2±1.9cm, whereas the length of the DGA (and its terminal articular branch) was 7.5±1.5cm. The mean length of the arterial pedicle for a cortico-periostal flap from the medial condyle was 9.92cm, whereas for the fascio-cutaneous perforator flap, it was 9.46cm in Y-shaped distribution and 10.2cm for the H-shaped distribution. Different arterial distribution patterns increase the need for routine preoperative vascular imaging when planning to harvest a cortico-periostal flap and a fascio-cutaneous perforator flap from the medial femoral condyle, especially when a double-chimeric flap is targeted. Level 4, case series.

In Situ Venous Bypass for Chronic Hand Ischemia: A Review of 25 Cases in 23 Patients.

Chronic ischemia of the hand in the setting of atherosclerotic disease is a challenging problem that leads to serial amputations and significant morbidity. Salvage using an in situ venous bypass has been described. In selected cases, leaving the vein in situ for bypass allows a good size match for anastomosis at the wrist or palmar arch. Due to the rarity of the condition, there is a paucity of data regarding the efficacy of this technique. Outcomes in 23 consecutive patients that underwent a total of 25 in situ vein grafts over a 16-year period were retrospectively reviewed. Eighteen were men and 5 were women with a mean age of 61 years. Target vessels at the wrist or palmar arch were identified on preoperative vascular imaging. The cephalic vein (n = 19, 76%) was most commonly used followed by the basilic vein (n = 6, 24%). Overall patency rate at a mean follow-up period of 12.1 months was 92%. Success as determined by both symptomatic improvement and resolution of the ischemic changes or toleration of revision amputation was achieved in 16 (64%) cases. Postoperative complications occurred in ten cases (40 %). Progression of ischemia occurred in 7 cases (28 %) and 3 (12 %) of these cases required a hand amputation. In situ vein grafts in the upper extremity offer good short-term patency rates and can be used for salvage of chronic hand ischemia.

Article Commentary: “Vertebral Artery Injury during Routine Posterior Cervical Exposure: Case Reports and Review of Literature”

Article Commentary: “Vertebral Artery Injury during Routine Posterior Cervical Exposure: Case Reports and Review of Literature”