Profunda Femoris Research Articles

Subclavian-carotid transposition and subclavian artery stenting for steal-syndrome

To analyze in-hospital results of subclavian-carotid transposition and subclavian artery stenting in patients with steal-syndrome. A retrospective open study included 137 patients with occlusion or severe stenosis of the first segment of subclavian artery and steal-syndrome. The 1st group included 50 patients who underwent stenting or recanalization with stenting of the first segment of subclavian artery between January 2010 and March 2020. The 2nd group included 87 patients who underwent subclavian-carotid transposition between January 2010 and March 2020. There were no in-hospital mortality, myocardial infarction, ischemic stroke or bleeding. In the second group, damage to recurrent laryngeal nerve with irreversible laryngeal paresis occurred in 6.9% of patients, and one patient had brachial plexus neuropathy. One patient developed lymphorrhea with chylothorax accompanied by shortness of breath on exertion. Conservative management with repeated pleural punctures was not accompanied by clinical compensation. The patient was discharged for outpatient treatment. Thromboembolism of the left branch of the aorto-femoral prosthesis and deep femoral artery on the left was diagnosed in the endovascular correction group after implantation of Protege GPS stent (10´60 mm) and post-dilation with a PowerFlex PRO balloon catheter (9´4 mm). Acute ischemia of the left lower limb required thrombectomy with patch repair of deep femoral artery. The patient was discharged after 5 days. In another case, vertebral artery dissection occurred after implantation of Protege GPS stent (10×40 mm) and post-dilatation with a PowerFlex PRO balloon catheter (8´20 mm). In this regard, the patient underwent stenting of the fourth segment of vertebral artery (Endeavor Resolute 4.0´24 mm stent) with post-dilation (Boston Scientific Samurai balloon catheter 0.014´190 cm). The patient was discharged after 3 days. Subclavian-carotid transposition and subclavian artery stenting are safe methods of revascularization that are not accompanied by myocardial infarction, ischemic stroke or mortality. However, subclavian-carotid transposition is characterized by higher risk of neurological disorders (laryngeal paresis, phrenic nerve paresis, brachial plexus neuropathy) and wound complications (lymphorrhea, chylothorax). In turn, subclavian artery stenting is associated with the risk of dissection and embolism. Therefore, the choice of treatment strategy in patients with occlusive-stenotic lesions of the first segment of subclavian artery should be personalized and carried out by a multidisciplinary team.

Hybrid revascularization in a patient with Covid-19 and chronic limb ischemia stage IV

The authors report hybrid treatment of a patient with angina pectoris class II, multiple previous reconstructive interventions on the aortofemoral segment and chronic ischemia of the left lower limb stage IV and concomitant COVID-19. Coronary angiography was performed after regression of infectious disease under antiviral therapy. Occlusion of the left anterior descending artery was observed that required LAD stenting. On the next day, hybrid revascularization of the lower extremities was implemented: thrombectomy and endarterectomy from the branch of the aorto-femoral bypass graft and deep femoral artery at the first stage, stenting of the orifice of proximal branch of aorto-femoral bypass graft at the second stage, endarterectomy from superficial femoral artery, recanalization and stenting of superficial femoral artery and popliteal artery at the third stage and prosthetic- femoral bypass with autologous vein at the fourth stage. Postoperative angiography revealed patent stents and no residual stenoses. The choice in favor of these procedures and step-by-step approach has been substantiated. The authors emphasized effectiveness and safety of this treatment strategy.

A Case of Endovascular Treatment of a Ruptured Pseudoaneurysm of the Deep Femoral Artery That Formed after Blunt Trauma

A Case of Endovascular Treatment of a Ruptured Pseudoaneurysm of the Deep Femoral Artery That Formed after Blunt Trauma

A case of femoral deep femoral artery injury in the bone marrow complicated by femoral diaphyseal fracture evaluated by contrast-enhanced CT

A case of femoral deep femoral artery injury in the bone marrow complicated by femoral diaphyseal fracture evaluated by contrast-enhanced CT

Application of Combined Superficial Femoral Artery Stenting and Deep Femoral Artery Profundoplasty in Chinese Patients With Lower Extremity Artery Disease.

Objective: Lower extremity artery disease (LEAD) increases sharply with age and results in severe burden in individuals and in society. This study aimed to compare the efficiency of simple superficial femoral artery stenting (SFAS) and the hybrid operation, such as combined SFAS and deep femoral artery profundoplasty (DFAP), in the treatment of Chinese patients with LEAD, classified as Rutherford grades 3–5.Methods: There were 200 patients with LEAD classified as Rutherford grades 3–5 included in the simple SFAS group (n = 100) and the combined SFAS and DFAP group (n = 100).Results: All the patients had median age of 71 years, and there were 143 males (71.5%). Not only the increase rate of ankle brachial index (ABI), but also reduction rate of Rutherford grade, were significantly higher after surgery in the combined SFAS and DFAP group than in the simple SFAS group (P < 0.05 for all). The patency rate of patients in the combined SFAS and DFAP group was significantly higher than that of patients in the simple SFAS group during the follow-up (P < 0.05). Proportion of amputation and claudication distance <200 m had no significant difference between the two groups during the 2-year follow-up (P > 0.05 for all).Conclusion: This study demonstrated that, compared with SFAS, combined SFAS and DFAP improved not only the ABI and the Rutherford grade after surgery but also the patency rate during the follow-up in Chinese patients with LEAD. Hybrid operation has significant value in alleviating clinical symptoms after surgery, and, thereby, improving vascular prognosis in Chinese patients.

Long-term results of proximal and distal reconstructions in patients with lower limb arteries diffuse lesions and diabetes mellitus

Relevance . Treatment of diffuse lesions of the arteries of the lower extremities is often reduced to primary amputation at the hip level, since the healing of trophic ulcers is not guaranteed during arterial reconstruction. Profundoplasty without distal bypass surgery can be considered an alternative method. The aim of this study is to compare the long-term results of distal shunting and isolated profundoplasty in patients with diffuse lesions of the lower limb arteries and trophic ischemic ulcers. Materials and Methods . The study included 86 patients with diffuse lesions of the lower limb arteries. There were 52 (60.4%) men and 34 (39.6%) women. The average age was 67.3 16.8 years. All patients had diffuse lesions of the arteries below the pupar ligament, the state of the lower leg arteries was 5-8.5 points on the Rutherford scale, in all cases there were trophic ulcers. Group 1 included 48 patients who underwent reconstruction of the leg arteries. Group 2 consisted of 38 individuals who had limited intervention with endarcteriotomy from common femoral and deep femoral arteries. Results and Discussion . Amputations at the hip level were performed within a year in 11 (23.4%) patients of group 1 and in 3 (6.3%) patients within 30 days after surgery. Thus, 14 (29.7%) patients lost their limbs. A comparative analysis revealed that the group of patients with amputations had a more severe form of diabetes (p = 0.003), an outflow score on the Rutherford scale (p 0.001), and lower transcutaneous oxygen tension values before and after surgery. Within 12 months after the bypass surgery, the primary patency of the shunts was 65.9% (thrombosis occurred in 16 patients). Conclusion . The preservation of the limb in patients in our study by the end of 1 year after reconstruction is similar regardless of the reconstruction method. Given the minimal invasion during profundoplasty, this operation may be the method of choice for diffuse lesions of the arteries of the lower extremities.

Fatigue and Vertigo Caused by a Femoral Arterio-venous Fistula

An 83−year old patient who had undergone coronary artery bypass grafting and several cardiac catheterisations was referred with fatigue and vertigo. Physical examination revealed a thrill in the groin. Duplex ultrasound, computed tomography angiography, and (A) digital subtraction angiography showed a short neck, high flow arteriovenous fistula (AVF) between the deep femoral artery (DFA) and common femoral vein (CFV). Coil embolisation was planned but not carried out owing to the short fistula neck. (B) The AVF, which consisted of a small vein crossing the DFA, most probably caused post-catheterisation, was ligated successfully. The patient remains asymptomatic.Image 1

The effect of the geometry of the proximal anastomosis, markers of apoptosis and cell proliferation on the long-term patency following reconstructive interventions on the femoropopliteal arterial segment

Aim. To study changes in the topography of the orifice of the deep femoral artery (DFA), markers of proliferation, and apoptosis in patients after open interventions on the femoropopliteal arterial segment.&#x0D; Methods. The study included 35 patients with atherosclerotic peripheral arterial disease (PAD), femoral-popliteal occlusion, stage IIBIII of the disease according to the classification of A.V. PokrovskyFontaine, who underwent open surgery. The average age of the patients was 694.6 years. These patients included 26 men. Patients were divided into two groups: group A included 18 patients who underwent femoral-popliteal prosthetics (distal End-To-End bypass anastomoses), group B included 17 patients with femoral-popliteal bypass surgery (distal End-To-Side bypass anastomoses). The groups were comparable in terms of age and disease severity (p 0.05). Determination of serum platelet-derived growth factor BB (PDGF BB) and soluble form Fas (sFas) levels was carried out immediately before the intervention, on the 1st, 7th days, and 1 month after the operation. Duplex scanning (DS) was performed on day 7, after 1 and 18 months. Statistica 10.0 software was used for statistical data processing. The significance of differences between unrelated samples was assessed using the Student's t-test. The correlations between variables were analyzed by using Pearson's method.&#x0D; Results. On 1st day, there was a decrease in soluble Fas in patients of group A compared with group B (0.41 ng/ml vs 0.78 ng/ml, p=0.01). On the 7th day, the levels of serum platelet-derived growth factor BB were increased in patients of group A compared with group B (35.2 ng/ml vs 23.2 ng/ml, p=0.00001). After 1 month, the level of serum platelet-derived growth factor BB in patients of group A remained elevated compared with those in patients of group B (22.8 ng/ml vs 14.4 ng/ml, p=0.0003).&#x0D; Conclusion. Femoropopliteal prosthetics leads to a change in branching angle of the deep femoral artery up to 7080%, accompanied by changing dynamics of apoptotic markers and cell proliferation, leading to an increase in the thickness of neointimal hyperplasia and the progression of atherosclerosis.

Hemorrhagic complications after endovascular interventions and the effectiveness of vascular closure devices

Aim. To identify the factors associated with hemorrhagic complications after endovascular interventions, as well as to assess the effectiveness of vascular closure devices.Material and methods. The study included 423 patients after endo - vascular intervention with femoral arterial access: 118 — manual compression, 305 — hemostasis using vascular closure devices (VCDs). The development of following complications was recorded: retroperitoneal hematoma, false aneurysm, arteriovenous fistula, bleeding, thigh soft-tissue hematoma. Time to hemostasis, immobilization period, and length of stay were assessed.Results. The complication rate was lower in VCD group compared to manual hemostasis (2,95 vs 11%, p=0,021). In VCD group, hemostasis characteristics significantly differed from the manual compression group: time to hemostasis — 3,1 vs 22,3 min (p=0,001), immobilization duration — 4,1 vs 20 hours (p=0,001), length of stay — 4 vs 8 days (p=0,001), respectively. The risk of complications increased with following factors: anticoagulant therapy, female sex, age &gt;65 years, diabetes, body mass index &gt;30 kg/m2 , vascular access calcification, introducer diameter &gt;6 Fr, prior puncture. There were following independent predictors of complications: glycoprotein IIb/IIIa inhibitor therapy, superficial or deep femoral artery puncture.Conclusion. VCDs significantly reduces the hemorrhagic complication rate and improves hemostasis parameters as compared to manual compression.

Application progress of profunda femoris perforating artery perforator flap in reconstruction of oral maxillofacial head and neck defects

各种原因引起的口腔颌面-头颈部缺损，常影响患者的语言、进食、吞咽等功能，并可能造成容貌损害，这会严重影响他们的生存质量甚至存活率。随着显微外科技术的发展，穿支皮瓣移植成为重建外科领域非常重要的技术手段之一。股深动脉穿动脉穿支皮瓣具有可观的穿支血管、充足的皮瓣面积、美观性能好且供区并发症少等优点，使其在口腔颌面-头颈部缺损重建的报道日益增多。.

Revascularization in Diabetic Foot Ulcer and Outcome

Diabetes is a major public health problem regionally and globally. In 2019, the International Diabetes Federation estimated that 465 million (9.3%) people worldwide had diabetes, and by 2045, the number may rise to 700 million (10.9%) [1]. The pooled prevalence of diabetes in the general population of Bangladesh is 7.8% and prevalence of pre-diabetes is 10.1% [2]. Diabetes is a complex disease with many serious potential sequelae, including large vessel arterial disease and microvascular dysfunction. The lifetime risk for foot ulcers in people with diabetes is estimated to be 15% [3]. Development of diabetic foot ulcer is attributed to many interacting factors, the most common ones being peripheral neuropathy and Peripheral Arterial Disease (PAD) [4]. PAD is an important precipitating factor in the outcome of diabetic foot ulcer [4]. Peripheral arterial disease is a common large vessel complication of diabetes, implicated in the development of tissue loss in up to half of patients with diabetic foot ulceration [5]. Diabetic patients with PAD commonly show involvement of the arteries below the knee, especially at the tibial and peroneal arteries, and involvement of the profunda femoris [6]. Diabetic ulcers always require vascular evaluation, and when ischaemia is suspected the diagnostics should be organized rapidly to ensure revascularisation without delay. Foot ulcer in patients with diabetes is associated with an increased risk of lower limb amputation, and thus the primary aim of treatment for ischemic foot ulcer is limb preservation [4]. Invasive revascularization, including open reconstructive surgery and/or endovascular intervention, is the most effective treatment that may improve peripheral circulation and remedy symptoms [4]. The basic aim of any successful revascularization is to achieve pulsatile flow to the foot. The two methods currently available are peripheral bypass surgery and peripheral angioplasty [7]. Current literature shows that percutaneous transluminal angioplasty (PTA) is the first choice of procedures in revascularization of the lower limb [7].

EP.FRI.42 REBOA associated iatrogenic AV fistula

Abstract Aim To discuss a rarely reported complication of Resuscitative endovascular balloon occlusion of the aorta (REBOA) in a trauma patient with exsanguating haemorrhage. Case description A 15 year old male sustained was brought in as a cod Red, following multiple stab injuries to his Rt thigh. A REBOA was inserted via the contralateral Femoral artery on the scene to control the bleeding. Once proximal and distal control was obtained on the Right leg, the REBOA was deflated and removed. The right leg needed an interposition vein graft and ligation of femoral vein. The patient had received 12 units of transfusion. Post-operative CT-angiogram demonstrated an AV fistula between the Left Profunda femoris artery and Common femoral vein on the side of REBOA insertion. A Duplex scan showed flows of 2600ml/min on duplex and AVF diameter of 2.6mm. It was decided to wait for spontaneously closure as patient underwent rehab. At 6 weeks the AVF flow had reduced to 460ml/min however further expectant management did not lead to spontaneous closure of the AVF and he underwent surgical tie off during his next school holidays 6 months later. Conclusion AV fistula formation as a complication of REBOA insertion has not been reported in paediatric population. It highlights the need for a CT angio after surgical stabilisation. These post traumatic AVFs may need surgical repair if it does not spontaneously close in 3-6 month time.

Follow-up on new marker confirming the optimal status in the treatment of heart failure with reduced ejection fraction

Abstract Background At the present time, there is no strong criterion to guarantee the optimal management for patients with heart failure and reduced ejection fraction (HFrEF). In the past, our group suggested the use of the size of the femoral vein (FV), measured by ultrasound as a marker of the fluid status in the venous compartment. Is this criterion still the best marker of optimal treatment of HFrEF at 3 years follow-up, especially for patients with significant co-morbidities (chronic obstructive pulmonary disease (COPD), end stage renal disease (ESRD) on hemodialysis (HD), cirrhosis of liver or sepsis? Methods Patients with HFrEF and co-morbidities as above were enrolled. All patients had echocardiography to confirm EF &amp;lt;45% and underwent the ultrasound test to assess the size and expansibility of the femoral vein (SEFV). The SEFV is the ultrasound study of the FV examining its size and expansibility with cough. The location of the femoral artery (FA) and FV to be checked is the coronal plane immediately proximal to the bifurcation of the superficial and deep femoral artery. The normal size of FV is a little larger than of the FA. If the size of the FV is twice larger than the FA, the patient has fluid overload in the venous compartment (Figure 1). Then the patient was asked to cough in order to measure the size of the FV. If the FV did not increase its size with cough, the venous compartment was full. If the FV increased its size, the venous compartment was not full and could accommodate more fluid. In physical exam, the fluid overload is proved by the presence of extravascular fluid in the abdominal wall, ascites or leg edema or in the intravascular compartment by the presence of the jugular venous distention. During the 3 years of follow-up, the patients were seen in the office and had the SEFV at regular 6 months intervals. A small group of patients also underwent right heart catheterization to measure to the pulmonary capillary wedge pressure (PCWP). Results 180 patients with HFrEF and significant comorbidities were enrolled. All patients were taught to follow a low Na diet, &amp;lt;2000cc of fluid restriction and the guideline directed medical therapy. After about 3 years, 75% patients in the study group were asymptomatic, was not readmitted to the hospital for HF, and the size of the FV was within normal range. Their physical exam showed no fluid in the extravascular compartment. The PCWP became lower than 24mmHg in 18/20 who underwent the RHC. There was significant weight loss (15 lbs). In the control group, 60% of patients were asymptomatic and 50% were not readmitted for HF (p&amp;lt;0.05). Conclusions With the SEFV test, the patients with HFrEF and significant comorbidities were accurately estimated for presence or absence of fluid overload. This SEFV test was especially sensitive to detect fluid overload in patients with multiple co-morbidities. Further randomized trials are needed to confirm the above preliminary results. Funding Acknowledgement Type of funding sources: None. Figure 1. Enlarged size of femoral vein

Peripheral Vascular Bypass with Cadaveric Arterial Allograft in a Toddler with FemoralMycotic Aneurysm

<h3>Introduction & Objective</h3> Mycotic aneurysms are exceedingly rare in the pediatric population. The optimal surgical treatment for children with this disease is unclear as aneurysm resection and vascular reconstruction are uncommonly performed in young children. We present the unique case of a21-month-old child with a complex cardiac history who presented with leg ischemia and a femoral mycotic aneurysm that was successfully repaired with an external iliac to profunda femoris artery vascular bypass with cryopreserved arterial allograft and femoral vein reconstruction. <h3>Case Report</h3> Our patient presented with leg ischemia and blood cultures positive for <i>Aspergillus</i>, with CT angiography demonstrating complete occlusion of the left common femoral artery and proximal superficial femoral artery (Figure 1Figure 1Axial computed tomography shows large left common femoral artery mycotic aneurysm with dense inflammatory reaction.Figure 1). Upon operative exploration, there was an extremely dense inflammatory response with purulent material extruding from the region and bulky reactive lymphadenopathy (Figure 2AFigure 2A-B. (A) Intraoperative photograph demonstrating large mycotic aneurysm involving the femoral artery. (B) Intraoperative photograph demonstrating the completed anastomosis between the left common iliac artery and the profunda femoris artery, along with femoral vein reconstruction.Figure 2) with extension of thrombosis from the external iliac artery immediately at the inguinal ligament to the superficial femoral artery. The 2 mm profunda arterywas the remaining outflow to the lower extremity. A 6 mm cryopreserved artery allograft (CryoArtery) was used to perform the vascular bypass between the external iliac artery and the profunda femoris artery in an end-to-side fashion. The mycotic aneurysm and underlying vesselswere dissected and resected from the external iliac artery to the proximal superficial femoral artery. As the femoral vein was densely adherent to the inflammatory mass, a segment was removed and reconstructed in a similar fashion with CryoArtery. Completed anastomosis is shown in Figure 2B. At the conclusion of the procedure, the patient had biphasic doppler signal in the dorsalis pedis artery. <h3>Conclusions</h3> Successful vascular reconstruction can be performed in a young child with an Aspergillus mycotic aneurysm using cadaveric arterial allograft. For our patient, a cryopreserved artery allograft was used as the iliofemoral bypass conduit. Although an autologous conduit would have been the preferred bypass method, it was not possible in this case owing to the patients immaturevenous system and prior surgical manipulation. Not only is restoring flow to the distal extremity of the utmost importance in young pediatric patients to avoid future limb-length discrepancies, but flow must also be maintained in the bypass conduit postoperatively without conduit occlusion. Our patient received intravenous heparin in the immediate postoperative period and was bridged to prophylactic enoxaparin for three months and aspirin indefinitely. If the use of an autologous conduit is not possible, we show here that a cadaveric arterial allograft can be a suitable and durable alternative and report the successful vascular reconstruction of a 20-month-old with an Aspergillus mycotic aneurysm using cadaveric arterial allograft and no limb-length discrepancy as of thirty-six months follow-up.

Re-discovering an Old Standard: Ilio-Femoral Bypass, with Adjunctive Procedures, for Primary orSecondary Iliac Artery Occlusion

<h3>Introduction and Objective</h3> Endovascular techniques constitute first-line treatment for iliac artery occlusions and enjoy outstanding primary and long-term durability. Some iliac occlusions are not amenable to endovascular repair because of calcification, chronic occlusion, and failed stents. Twenty-eight patients with unilateral iliac occlusion who were not candidates for or failed endovascular repair underwent ilio-femoral bypass. Extra-anatomical bypass was avoided because of previous contralateral procedures or risk to the contralateral extremity. This abstract reviews one surgeon's experience with ilio-femoral bypasses from December, 2014 to November, 2020. <h3>Case Report</h3> Twenty-eight (28) patients, 74% males, with an average patient age of 63.8 years and unilateral iliac occlusion, underwent ilio-femoral bypass. 88% were smokers, 38% were diabetics, and 30% had severe heart disease. Two patients had severe kidney disease requiring dialysis. Twenty-four patients underwent previous attempts at revascularization: 14 received iliac stents and 4 patients had failed aorto bifemoral or axillo/ilio femoral bypasses. There were 6 previous open interventions involving the femoral arteries. Two patients sustained rupture while undergoing endovascular procedures and required emergent bypasses. Indications for intervention were rest pain in 11, tissue loss in 8, and disabling claudication in 5. There were 3 urgent interventions: two required immediate intervention following rupture of an iliac artery angioplasty, and a third occurred during insertion of a thoracic stent. One procedure was performed fora 2-year-old infected iliac bypass with impending rupture. All operations were performed under general anesthesia. Proximal retro-peritoneal exposure of the iliac arteries was obtained via a curvilinear incision in the ipsilateral lower quadrant. Twenty-four (24) patients received a Dacron conduit, 2 PTFE, 1 bovine, and 1 femoral vein. Thirty-five (35) adjuvant procedures were done in conjunction with the bypass. In 14 cases (54%,) retrograde endarterectomy/thrombectomy/stent extraction was performed. Eleven patients (35%) required a femoral endarterectomy/thrombectomy. Angiography was used selectively if inflow was deemed inadequate. Six (6) intraoperative angiograms were needed with 2 patients requiring proximal stent insertions. Two patients received simultaneous femoral to distal bypasses done for tissue loss. <h3>Results</h3> Procedures were technically successful in 100% of patients. All bypasses were patent at the time of their loss to follow-up or death. Patients were followed for an average of 22.3 months. No secondary interventions were required. There was 1 groin infection that required excision of the graft; one above knee amputation was required for an infected knee prothesis. There was one groin hematoma. Two patients died within thirty days (8%), one from SIRS (multi-organ system failure following recent myocardial infarction) and one patient died of a coagulopathy following rupture of a calcified common iliac artery during angioplasty. There were no amputations due to vascular disease. 100% patency in this series was enhanced by adjunctive procedures. Ilio-femoral bypasses done to symptomatic elderly patient with occluded superficial femoral arteries frequently enjoyed relief of rest- pain without the morbidity of distal incisions. This group required endarterectomy of the common and deep femoral arteries. No hernias, local nerve injuries, lymphorrhea, damage to ureters, or major infections occurred. One groin infection was a catabolic, nursing home patient with an infected, ischemic, above knee residual limb. He required excision of the exposed graft. Patients tolerate the retroperitoneal approach usually without paralytic ileus and prompt restoration of bowel function. Respiratory insufficiency is also minimal since a major body cavity is not entered. The majority of patients were extubated before transfer to the post-operative acute care unit. <h3>Discussion</h3> Historically, ilio-femoral bypass is considered a durable operation with a cumulative patency of 92% 3- year patency and exhibit superior patency when compared to extra-anatomical bypasses that demonstrate a 73% 3-year patency. The operation has been largely supplanted by endovascular procedures which are equally durable and less invasive. There is a subset of patients in whom angioplasty/stents are not possible or who have failed endovascular intervention and require in flow procedures. In this series, ilio femoral bypass was only performed in 5 patients (19%) with claudication.The remaining patients had critical limb ischemia and required intervention for limb preservation. Ilio-femoral bypass with adjunctive procedures provided acceptable short term and mid-term results in complicated patients, 85% of whom had previously undergone ipsilateral vascular intervention.

Peripheral Angioinvasive Aspergillosis in the Setting of End-Stage Liver Disease

Invasive aspergillosis of the peripheral arteries is a rare complication in vascular surgery. Angioinvasion can compromise vascular wall integrity, leading to local and systemic complications. We report the case of peripheral angioinvasive aspergillosis of the common femoral artery (CFA) and superficial femoral artery in a patient with decompensated alcoholic liver cirrhosis. We reviewed the electronic medical records for the patient's medical history, diagnostic imaging, operative reports, and in-hospital course. All information was de-identified. A 58-year-old man with advanced alcoholic liver cirrhosis had presented to our tertiary care center for orthotopic liver transplant evaluation. A part of the workup included coronary angiography, which was performed through a 6F femoral sheath access. Subsequently, the patient developed right groin hematoma with a CFA pseudoaneurysm and evidence of femoral nerve compression. He underwent hematoma evacuation and CFA repair that required endarterectomy. His postoperative course was complicated by a recurring surgical site hematoma requiring transfusions, several groin reexplorations, and creation of a sartorius flap to provide coverage of the femoral vascular bundle. A vacuum-assisted closure device was used for wound dressing. During the ensuing days, sartorius flap necrosis developed, and the patient experienced acute arterial bleeding. On reexploration, the CFA was noted to have sieve-like bleeding with complete disintegration of the arterial wall. Ligation of the CFA, profunda femoris, and superficial femoral artery as lifesaving measures was required. The patient's condition continued to worsen, with liver failure and right leg ischemia. After the goals of care were discussed with the family, they decided for terminal extubation, after which the patient died. Evaluation of samples of the femoral vessels obtained during surgery returned positive for the presence of Aspergillus species on fungal stains within the arterial wall, with large fungal bodies protruding into the vessel segment lumen (Fig). Distorted vessel wall anatomy was also observed with dense infiltration and hyphae and evidence of vessel microperforation. The presence of invasive aspergillosis was most likely responsible for the arterial wall disintegration. Peripheral angioinvasive aspergillosis is a rare infectious complication in vascular surgery and can occur in patients with end-stage liver disease. Angioinvasion is difficult to treat and can result in vascular wall compromise, presenting as life-threatening hemorrhage.

Primary Patency of Infrainguinal Bypass is Correlated to the Quality of the Profunda Femoral Artery

Primary Patency of Infrainguinal Bypass is Correlated to the Quality of the Profunda Femoral Artery

Wall shear stress mapping for human femoral artery based on ultrafast ultrasound vector Doppler estimations.

Wall shear stress (WSS), a type of friction exerted on the artery wall by flowing blood, is considered a crucial factor in atherosclerotic plaque development. Currently, achieving a reliable WSS mapping of an artery noninvasively by using existing imaging modalities is still challenging. In this study, a WSS mapping based on vector Doppler flow velocity estimation was proposed to measure the dynamic WSS on the human femoral artery. Because ultrafast ultrasound imaging was used here, flow-enhanced imaging was also performed to observe the moving blood flow condition. The performance of WSS mapping was verified using both straight (8mm in diameter) and stenosis (70% of stenosis) phantoms under a pulsatile flow condition. A human study was conducted from five healthy volunteers. Experimental results demonstrated that the WSS estimation was close to the standard value that was obtained from maximum velocity estimation in straight phantom experiments. In a stenosis phantom experiment, a low WSS region was observed at a site downstream of an obstruction, which is a high-risk area for plaque formation. Dynamic WSS mapping was accomplished in measurement in the femoral artery bifurcation. In measurements, the time-averaged WSS of the common femoral artery, superficial femoral artery, and deep femoral artery was 0.52± 0.19, 0.44 ± 0.21, and 0.29 ± 0.16Pa, respectively, for the anterior wall and 0.29 ± 0.11, 0.54 ± 0.24, and 0.23 ± 0.10Pa, respectively, for the posterior wall. All results indicated that WSS mapping has the potential to be a useful tool for vessel duplex scanning in the future.

Anatomical Variations of Medial Circumflex Femoral Artery – A Cadaveric Study

Introduction: The Profunda femoris artery is a large branch that arises from the lateral or posterolateral part of the femoral artery, about 3 to 5cm below the inguinal ligament. Profunda femoris artery [1,2,4] gives Medial circumflex femoral artery, Lateral circumflex femoral artery, and Perforating arteries and muscular branches. Medial circumflex femoral artery (MCFA) originates from the posteromedial aspect of the Profunda but may originate from the femoral artery. It gives three branches ascending and transverse, acetabular branches. Aim & Objectives: To study the anatomical variations in source of origin, site of origin of MCFA. Methods: The present observational study was conducted on the dissection of 70 lower limbs of 35 adult cadavers (27 male & 8 female). Contents of the femoral triangle were dissected as per Cunningham’s manual. The source of origin distance of the origin of MCFA was noted. Collected data were analyzed statistically. Results: In the present study, MCFA from the P.F.A. in 85.71% (60/70) in both Right and Left lower limbs. The common source of Right MCFA from the Femoral Artery followed by a common stem with P.F.A. The following common source of Lt MCFA as a common stem with P.F.A. Distance of origin of MCFA from the P.F.A. was seen between 1-2cm in 34.29% of Right and 28.5% of Left Limbs in the present study. Conclusions: In most limbs (60/70 limbs), the MCFA was taking origin from P.F.A. in both Right & Left limbs (85.72%). Distance of origin of MCFA from the P.F.A. was seen between 1-2cm in 34.29% of Right and 28.5% of Left Limbs in the present study.

A VARIATION IN ORIGIN OF BRANCHES OF PROFUNDA FEMORIS ARTERY IN RELATION WITH FEMORAL ARTERY: A CASE REPORT

Introduction – Profunda femoris is the main course of supply to the muscles of thigh area. It is the biggest part of femoral supply route in the thigh region. It gives out branches named medial circumex femoral and lateral circumex femoral and four perforating branches and proceeds as the fourth perforating branch in the mid of thigh. A variation regarding the branching pattern of profunda femoris artery was observed with an origin of medial and lateral circumex arteries is been seen in a formalin embalmed 55 years of age female cadaver during typical dissection procedure in the dissection hall. Methods - The study was undertaken on lower limb of a fully embalmed 55years old female cadaver in the department of anatomy, used for routine dissection for teaching undergraduate and post graduate medical students. Result - In this female cadaver on left side of lower limb, there was an uncommon origin of lateral circumex femoral artery directly from the femoral artery with a normal emergence of medial circumex femoral artery from profunda femoris artery. While on the right side of the same Cadaver, the profunda femoris artery arose at usual distance i.e., 3.7cm below inguinal ligament, from posterolateral aspect of femoral artery and then it bifurcates into lateral and medial circumex femoral artery. Conclusion - Current examination will assist the clinicians to bypass iatrogenic inconveniences during a surgical procedure and will likewise help them in methodology for interventional radiology around this region.