Transposition Technique Research Articles

An Application of Combined Transpetrosal Approach with Micro-neurovascular Transposition in Recurrent Trigeminal Neuralgia caused by Dolichoectatic Vertebral Artery

PurposeIn general, the superior cerebellar artery (SCA) is the most prevalent vessel that compresses the trigeminal nerve root exit zone (TGNREZ) and is responsible for trigeminal neuralgia (TGN). Nevertheless, the surgical outcome is less efficacious when the offending vessel is a dolichoectatic vertebrobasilar vessel (DVB). In addition, the potential for post-procedural adhesion and fibrosis renders recurrent TGN after prior surgery an extremely challenging operation. MethodsWe describe our surgical strategy and procedure that effectively resolved recurrent TGN in a patient whose offending vessel was a large DVB following standard microvascular decompression surgery. The size and nature of the offending DVB indicated that there was limited space for mobilization away from the TGNREZ, as evidenced by previous operative findings. Consequently, the patient's TGN may not be effectively treated by re-operating with the same standard lateral suboccipital approach. ResultsOur surgical approach comprised the creation of an expanded area to facilitate the mobilization of the DVB from the TGNREZ, as well as the untethering of the trigeminal nerve and its subsequent mobilization from the DVB using the transposition technique. ConclusionA combined transpetrosal approach with micro-neurovascular transposition technique was selected to achieve all objectives. A case illustration with a surgical video is demonstrated.

Surgical Strategies for Endoscopic Endonasal Access to the Retrosellar Region: Evaluating the Type of Pituitary Transposition Technique Based on Disease

Surgical Strategies for Endoscopic Endonasal Access to the Retrosellar Region: Evaluating the Type of Pituitary Transposition Technique Based on Disease

Modified musculofascial lengthening technique for submuscular ulnar nerve transposition in cubital tunnel syndrome.

Cubital tunnel syndrome is a common peripheral neuropathy of the upper extremity. Anterior transposition of the ulnar nerve is an established surgical treatment option for this condition. This study aimed to introduce a novel musculofascial lengthening technique that uses only a portion of the flexor-pronator muscle mass for submuscular anterior transposition of the ulnar nerve and investigate its clinical outcomes. We evaluated 28 patients (29 cases; 1 patient had bilateral involvement) diagnosed with cubital tunnel syndrome who were treated with surgical decompression and submuscular anterior transposition of the ulnar nerve using our novel technique. Mean follow-up was 19.1 months (range, 12-31). Patient-reported outcomes were assessed using the Boston Carpal Tunnel Questionnaire (BCTQ), Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire, and numeric rating scale (NRS) for pain. Objective outcomes including light touch perception, static two-point discrimination, and grip strength were also assessed. Modified Bishop score and postoperative complications were also evaluated. BCTQ symptom severity and functional status scores, DASH score, and NRS for pain score showed significant improvement after surgery. Light touch perception, static two-point discrimination, and grip strength also significantly improved after surgery. All patients showed excellent or good results according to the modified Bishop scoring system. No recurrence or complications occurred. Our novel musculofascial lengthening technique that uses only a portion of the flexor-pronator muscle mass for submuscular anterior transposition of the ulnar nerve reliably achieves good results with minimal complications in patients with cubital tunnel syndrome.

Long-term evaluation of Elmelegy’s technique of local muscle transposition for the functional restoration of large upper or lower lip defects

BackgroundAlthough more than 200 techniques have been reported for the reconstruction of the upper and lower lip defects since 1000 BC, none of them is ideal.Local flaps may result in extra skin incisions and in some cases, the surgeon may be confronted with the lack of sufficient tissues for the reconstruction of large defects.Several techniques have been described for near-total lip reconstruction. The two major available techniques are local flap reconstruction (Bernard–von Burrow–Webster technique) and free micro-vascular tissue transfer.In this study, we are going to evaluate the functional results of using local muscles transposition-assisted dermal fat flap and muco-buccal flap in the treatment of large upper or lower lip defects.Materials and methodsThis study was carried out on 128 patients, who presented to us with malignant tumors affecting the lips.ResultsLip defect sizes ranged from 4 to 6 cm in diameter. No flap failure was seen and desirable function and accepted esthetic results were obtained. The flap survival was 100%, and healing was eventful in all cases. No cases of microstomia were reported.ConclusionThe use of local muscle transposition-assisted dermal fat flap and muco-buccal flap technique, showed excellent results in regaining oral competence and lip mobility, and as much as possible, increased the aesthetic outcome.Level of evidenceIV therapeutic study.

Endoscopic pituitary gland transposition techniques to the interpeduncular and prepontine regions: an anatomical study.

The floor of the third ventricle and the interpeduncular and prepontine regions represent challenging surgical targets. The expanded endoscopic endonasal approach (EEA) with pituitary gland (PG) transposition has been proposed to provide direct access to these anatomical regions. Through the years, different endoscopic PG transposition techniques have been studied and presented. The goal of this study was to compare the techniques, relevant anatomy, and surgical exposure of extradural, intradural, and interdural PG transposition techniques. Six formalin-fixed, latex-injected cadaveric head specimens were used to perform the EEA with extradural, unilateral interdural, and unilateral intradural PG transpositions. The interpeduncular and prepontine regions and the neurovascular structures located within these cisterns were carefully exposed and analyzed. The maximal cranial, caudal, and lateral accessible points within the surgical field were identified for each approach. Consequently, the relative craniocaudal and horizontal surgical axes were measured to quantify the extent of accessibility of each approach. The extradural PG transposition technique provided the largest horizontal extensions and bilateral access to structures within the interpeduncular and prepontine regions; the mean horizontal axis was 17.9 (range 13.9-20.4) mm. The unilateral interdural PG transposition provided wider vertical exposure, with a mean craniocaudal axis of 16.2 (range 13.0-20.9) mm. In this approach, the surgical field was extended cranially above the ipsilateral mammillary body (MB). The unilateral intradural PG transposition provided a similar surgical exposure to the interdural approach, with a mean craniocaudal axis of 14.7 (range 12.9-15.8) mm. The approach required significant manipulation of the PG after opening both periosteal and meningeal dura layers. The extradural PG transposition is indicated for lesions of the upper clivus region that extend bilaterally and do not have a cranial extension beyond the MBs. The inter- and intradural PG transpositions are beneficial for unilateral lesions that extend cranially to the MBs. Both techniques require coagulation of the ipsilateral inferior hypophyseal artery. The intradural technique requires more manipulation of the PG, while the interdural technique requires opening and access to the cavernous sinus. If needed, the intra- and interdural techniques can also be performed bilaterally.

Interposition versus transposition technique in microvascular decompression for trigeminal neuralgia secondary to vertebrobasilar dolichoectasia: a systematic review and pooled meta-analysis.

Limited data are available comparing the interposition and transposition techniques for microvascular decompression (MVD) in patients with trigeminal neuralgia (TN) secondary to vertebrobasilar dolichoectasia (VBD); this study aims to review current findings on TN associated with VBD and compare the interposition and transposition techniques in terms of surgical morbidity and patient outcomes. Following the PRISMA guidelines, PubMed/Medline, Web of Science, and SCOPUS databases were searched to identify studies reporting patients undergoing MVD for TN secondary to VBD. The studies were divided into two groups, interposition and transposition, based on the microvascular decompression technique used. Studies not reporting the diagnostic criteria, included less than five cases, or were not available in English were excluded. Fourteen eligible papers were retrieved, of which five studies reported cases undergoing the interposition technique, eight studies for the transposition technique, and one study reported cases from both groups. Data including preoperative and postoperative BNI class, comorbidities, and postoperative complications were retrieved to analyze and compare the two techniques in terms of efficacy and long-term outcomes in treating TN secondary to VBD. Both interposition and transposition techniques for MVD yield high rates of pain relief in patients with TN secondary to VBD. While both approaches demonstrate similar efficacy, the interposition method is associated with a lower rate of long-term complications. Further research, preferably through randomized prospective studies, is needed to refine surgical strategies and improve patient outcomes.

Use of the Martius Flap for Tethered Vagina Syndrome After a Single-Incision Mini-Sling Procedure.

Tethered vagina syndrome is an iatrogenic, but poorly defined condition that usually develops after surgical procedures performed on the anterior vaginal wall. Loss of elasticity as a result of scarring in the bladder neck-urethra is blamed for its pathogenesis. Patients often present with typical, massive uncontrollable urine loss and have specific examination findings. Having awareness about the diagnosis is important for its management. Surgical restoration and maintenance of bladder neck elasticity are essential for treatment. In our case, we presented the surgical approach we applied to tethered vagina syndrome that developed after the single-incision mini-sling operation. We demonstrated the surgical technique of Martius flap transposition and showed that this flap can be used to maintain the elasticity of the bladder neck area of the vagina.

«Слово на погребенïи честныя жены» Симеона Полоцкого в контексте «образцовых» погребальных проповедей XVII века

The study attempts to investigate sources and the so-called “library resource” or texts that were used by Simeon Polotskij for the funeral sample sermon “Slovo ma pogrebenii chestnyia zheny” (“Sermon for the funeral of an honourable woman”) from sermon’s collection “Vecherya Dushevnaia” (“Spiritual Evening Meal”), 1683. The study confirms existed in the literature disparate observations about the significant commonality of the sources of inspiration and factual material of Simeon’s sermon collections and his poetic encyclopaedia “Vertograd mnogotsvetnyi” (“A Garden of Many Flowers”; poetry sources identified by Anthony Hippisley); in particular, that in both cases Simeon used Latin collections of annual sermons by Bavarian Jesuit Matthias Faber (1586(87)–1653). The study analyses techniques of translation and transposition of the Latin text used by Simeon; notes errors made in the process of working with Faber's sermon that distort the attribution of certain quotations; identifies cases of Simeon's use of Latin winged phrases. The analysis of genry features of Simeon’ “Slova ma pogrebenii chestnyia zheny” in the context of the funeral sample sermons for women in the Polish-Lithuanian Commonwealth, 17th C. (homiletic collections by Protestant theologian Samuel Dambrowski, 1577–1625, and Polish Jesuit Aleksander Lorencowicz, 1609–1675) showed that the preachers’ funeral sample sermons were often universal and could be used for both “women’s” and “men’s” sermons, depending on the situation.

Microvascular Decompression for Trigeminal Neuralgia Secondary to Vertebrobasilar Dolichoectasia: Review of the Literature and Illustrative Case.

Classical trigeminal neuralgia (TN) is a chronic pain disorder characterized by severe, unilateral facial pain, often resulting from vasculonervous conflict. A less common cause of TN is vertebrobasilar dolichoectasia (VBD). Microvascular decompression (MVD) is the preferred surgical intervention for TN, but in case of VBD, the surgical procedure is more complex due to the aberrant vascular anatomy. This study aims to review the evidence on MVD for VBD-induced TN, and analyze operative challenges, efficacy, and postoperative outcomes. An illustrative case is also presented. We report on the case of a 62-year-old male with a 7-year history of right-sided TN affecting the maxillary (V2) and mandibular (V3) territories. The patient underwent MVD using the interposition technique, where Teflon sponges were placed between the basilar artery and the nerve. Postoperatively, the patient experienced complete pain relief without neurological deficits. At 12 months follow-up, the patient remained pain-free and off medications. We performed an extensive literature review using PubMed, Scopus, and Web of Sciences, highlighting the most relevant studies and findings on the topic. The literature review showed that, while MVD is effective in providing long-term pain relief in VBD-induced TN, the choice between interposition and transposition techniques remains debated. Interposition is easier to perform but may inadvertently increase nerve compression in some cases, whereas transposition offers more definitive decompression but carries higher technical risks. Our case and the available literature highlight the importance of individualized treatment planning in achieving optimal outcomes for patients with VBD-induced TN. Further research is needed to refine surgical techniques and minimize complications in this subset of TN patients.

“He would do nothing in the office”: Work and alienation in cinematic adaptations of Herman Melville’s Bartleby.

This paper analyzes the representation of the office workplace in filmic adaptations of Melville’s short story “Bartleby, the Scrivener”. Following a brief overview of film adaptations of Melville’s short story, this article will discuss Miro Bilbrough’s (2001) and Gerard Amsellem’s (2013) short films, Andreas Honneths (2010) experimental interpretation as well as Laura Naylor and Kristen Kee’s (2017) stop-motion movie. By, for instance, analyzing how the movies try to replicate the first-person narration, find visual images for Melville’s uncinematic descriptive prose, or underline the thematic importance of writing by incorporating different forms of written text, I will firstly examine techniques of intermedial transposition. Since the filmmakers deploy the setting to reimagine or modernize the story, the set design is to be regarded as an essential part of the adaptation process. Paying particular attention to the usage of space, the visual presentation of physical and metaphorical walls, as well as the utilization of non-human entities as ‘actors,’ I will seek to demonstrate how the movies under study reflect contemporary office environments and dynamics of work culture. Updating the nineteenth-century quills and inkpots to modern office technology, for example, allows the directors to reflect upon how electronic communication can cause or reinforce isolation. Different concepts of alienation serve as an essential theoretical framework for the movies. The adaptations concern themselves with social disconnect, engage in questions of ecological alienation, or focus on a political and socioeconomic interpretation of Bartleby’s passive resistance to productivity and consumption.

Sublimbal orbital fat transposition in neurotrophic keratopathy: a case series

Neurotrophic keratopathy is a progressive condition resulting from corneal denervation, leading to the development and persistence of corneal ulcers. Among the pathogenetic treatment methods there are corneal neurotization, a technically challenging approach associated with a prolonged rehabilitation period, and the usage of recombinant human nerve growth factor (cenegermin), which is practically inaccessible due to its high cost and lack of registration in Russian Federation. We propose a technique of orbital fat transposition to the sclerocorneal pocket for the treatment of persistent ulcers associated with neurotrophic keratopathy. This method is based on neuronal embryology of orbital adipose tissue, as well as the abundance of neurotrophic factors and stem cells. This method was applied to three patients with different etiologies of neurotrophic keratopathy, reaching the observation endpoint in two months after the operation. Visual acuity was ranging from 0.005 to 0.01. All patients received standard therapy for 1–2 months without significant improvement. Surgery was then performed using the proposed technique, which involves repositioning the medial and central orbital fat pads into the sclerocorneal pocket. In the postoperative period, partial epithelialization was observed in all patients during the first week, followed by complete healing and scar formation. The maximum visual acuity in 2 months ranged from 0.06 to 0.3.

Scalp defect associated with extensive fibrosis of artificial dura requiring modified closure

Background A variety of methods are available for scalp defect closure and necessitate extensive planning. Superficial temporal artery (STA) based local flaps are widely used in the field of scalp and face reconstruction because of their flexibility and rich vascularity. Rotation and transposition techniques are commonly used in the area, however at times result in excessive tension. V-Y advancement allows tension-free closure with reduced post-operative complications. Case presentation A case of scalp defect post multiple craniectomies for a traumatic head injury complicated with subgaleal collection and poor wound healing in a 29-year-old male, is reported. Due to the nature of defect, with underlying fibrosis and previous artificial duraplasty, along with location in the frontotemporal region, a local STA based flap closed in a rotation, transposition and unilateral V-Y advancement pattern was used. Conclusion The challenges encountered in wound closure of complicated post-traumatic and multiple craniectomy cases can be overcome with a modified combined approach which achieves optimal wound closure. Bangladesh Journal of Medical Science Vol. 23 No. 04 October’24 Page : 1227-1232

Long-term Outcome of Conjunctival Transposition Flaps for Contracted Sockets.

To assess the efficacy, and reintervention rate, of a conjunctival transposition technique in the treatment of contracted fornices in anophthalmic sockets. Retrospective case-note review of patients with contracted anophthalmic sockets who received a novel conjunctival mucosal transposition flap for augmentation of socket lining. Contracted anophthalmic sockets were categorized as grade 1 (minimal contraction), grade 2 (inferior and/or superior fornix), grade 3 (advanced scarring of the entire upper and lower fornices), and grade 4 (severe palpebral phimosis, recurrent cases, and irradiated sockets). Of 32 patients (56% male), 53% had mild-to-moderate contracted anophthalmic sockets (grades 1 or 2). The transposition flap was combined with secondary ball implantation (3 cases), ball exchange (1 case), primary orbital floor (1 case), or revisional floor (3 cases) implantation. By an average follow up of 9.2 years, 16% (5 cases with grade 3 or 4) required additional relining, with another patient declining further surgery; this yielding an overall anatomic success of 81% (100% in grades 1 and 2; 60% in grades 3 and 4). At the last follow up, 91% of patients had adequate socket lining and 94% reported a comfortable socket with stable prostheses. Having results similar to free grafting but without remote donor-site morbidity, this novel transposition flap satisfactorily addresses mild-to-moderate fornix contracture, and most patients achieve stable and comfortable prosthetic wear. Some patients with severe contracted anophthalmic sockets required further autologous grafting: this generally arose because the transposition flap included tissue from above the socket's horizontal raphé (with later contracture of the upper fornix).

Novel Technique for Ulnar Nerve Transposition at the Elbow: The Neocubital Tunnel.

Many standard surgical procedures for cubital tunnel syndrome rely on ulnar nerve transposition at the elbow. Placing the ulnar nerve anterior to the axis of motion decreases compression during flexion. Subcutaneous, subfascial, and submuscular positioning of the ulnar nerve may predispose to nerve irritation, instability, and compression in the two first scenarios, and requires invasive dissection in the third one. With no single procedure demonstrating clear advantages and outcomes, this study reports the results of a novel technique using the epitrochleo-olecranon ligament to create a neo-tunnel, anatomically stabilizing the ulnar nerve. Nine consecutive patients were enrolled. Patients were evaluated qualitatively for symptomatic improvements using physical examination. The Wilson and Krout, modified McGowan, and PRUNE grading scores were used for quantitative measurement. Postoperatively, all patients reported subjective improvement in symptoms and functional improvement. There were no intraoperative or postoperative complications. Baseline severity of disease was evaluated using the McGowan scale (modified by Goldberg): eight (89%) grade IIA patients and one (11%) grade III patient. Postoperatively, seven (78%) patients were reduced to grade 0, and two (22%) patients to grade 1 (P < 0.001). Using the Wilson and Krout criteria, outcomes were as follows: six (67%) excellent, two (22%) good, and one (11%) fair. The mean postoperative PRUNE survey score was 19.3 (SD ± 24.4). The neocubital tunnel technique is a relatively noninvasive, safe surgical alternative that may be considered when an anterior transposition of the ulnar nerve is indicated for surgical decompression of the cubital tunnel.

Iliac transposition technique for reconstruction of aortic bifurcation in pediatric blunt abdominal aortic injury

Blunt abdominal aortic injuries, especially in pediatric patients, represents a rare and critical challenge. We report a unique case of a 10-year-old boy who presented after a high-speed motor vehicle collision resulting in injury to the aortic bifurcation, alongside other intra-abdominal trauma. A novel surgical approach for aortoiliac reconstruction in a contaminated field was used. This technique consisted of the mobilization of the distal aorta and common iliac arteries, ligation of right internal iliac artery, and creation of aortoiliac and common to internal iliac artery anastomoses. This method demonstrates a potentially lifesaving technique in select patients.

Advancing process-based flood frequency analysis for assessing flood hazard and population flood exposure

Recent studies have showcased the use of process-based hydrological models with Stochastic Storm Transposition (SST) techniques to conduct Flood Frequency Analysis (FFA). This framework, referred hereby FFA-SST, has proved to be a robust strategy to estimate peak flows of specific annual exceedance probability (e.g., 100-year peak flow) that can reflect natural and anthropogenic disturbances, including changes in land use and meteorological patterns. With the objective of advancing the FFA-SST framework, this study presents for the first time the use of a spatially-resolved Integrated Surface-Subsurface Hydrological Model (ISSHM) to conduct FFA-SST. This allows us to extend the analysis from peak flow responses to flood extent, enabling a unique view and analysis of flood hazard and population flood exposure at the basin scale. As a proof-of-concept, we used the ISSHM, Amanzi–ATS, and the SST model, RainyDay, to conduct FFA-SST by simulating the flood response to 5000 annual synthetic storm events in a ∼2000km2 Southeast Texas watershed. We demonstrate that ATS, without site-specific calibration, provides a robust process-based representation of peak flows, flood extent, streamflow, evapotranspiration, soil moisture content, and water storage changes. Our results and analyses, covering frequency curves up to a 500-year return period for peak flows, basin inundation fractions, and the number of people exposed to flooding, offer a unique perspective to analyze flood impacts across spatial scales. Overall, this study provides critical insights for flood risk management by extending the FFA-SST framework to include both flood hazard and population flood exposure analyses at the basin scale. Such an approach will empower stakeholders and disaster emergency agencies with a more comprehensive understanding of flood impacts across the entire basin domain, facilitating informed decision-making for flood risk assessment and management.

Calculation on Current Distributions among Transposed Three- and Six-parallel Conductors in Superconducting Armature Coils for Superconducting Synchronous Motors

Abstract The armature coil of the superconducting synchronous motor for electric aircraft requires a current of 1,000 A or more. However, a single superconducting tape at liquid nitrogen temperatures is insufficient for this operating current. Therefore, the armature coil should be composed of multi-strand parallel conductors. If the coil is constructed from parallel conductors, the inductance balance between the parallel conductors will be collapsed, so the current distributions will be non-uniform. As a solution for this issue, the uniform current distribution can be achieved by the transposition technique that changes the order in which tapes are stacked. Our previous research has developed the transposition method for the 2 n -strand parallel conductors (n = 1, 2, 3, and so on). However, some of the superconducting synchronous motors are actually designed using a number of parallel conductors other than 2 n . This study focused on the three- and the six-strand parallel conductors. We analytically clarified the unique transposition configuration for the three-strand parallel conductors that achieves uniform current distribution, and the transposition configuration for the six-strand parallel conductors by combining the transposition configuration for the three- and two-strand parallel conductors. As a result, the current distribution ratio became less than ±5% when the number of turns of the double pancake coil was a multiple of six by applying the transposition.

#865 Autologous cephalic vein transposition in the placement of forearm arteriovenous fistulas

Abstract Background and Aims The autologous vein transposition was commonly used for hemodialysis vascular access (VA) in selected patient. The saphenous vein was used as a vascular graft; while, the contralateral cephalic vein was used as a bridge. We describe a new technique of autologous cephalic vein transposition to create a native AVF in hemodialysis patients. Method Patients referred to our hospital for a vascular access placement. US vascular mapping of upper extremities revealed small arteries, but adequate forearm veins in all patients. Specifically, the radial artery luminal diameter was &amp;lt; 1.4 mm and &amp;lt; 1.6 mm, respectively at wrist and at middle-arm. While, at bend of the elbow, the ulnar artery diameter (&amp;gt;2.5 mm) in one case, and the brachial artery diameter (&amp;gt;3.5 mm) in two cases, were deemed adequate as feeding arteries of a possible AVFs. Furthermore, the diameter of the forearm cephalic vein ranged from 2.0 to 2.4 mm; in the upper arm the veins were obstructed or stenotic in one of the two arms. The basilic vein was patent in both arms of the patients; the internal diameter varied from 2.5 to 2.7 mm. Due to difficulty to create a traditional fistula, and higher risk of primary failure, it was decided to transpose the cephalic vein, from the forearm not suitable for the AVF, to the contralateral arm chosen for the AVF placement. Results With local anesthesia, an approximately 10-cm stretch of cephalic vein was harvested from the arm contralateral to the site chosen for AVF. Then, the transposed veins, reversed in their cranio-caudal position, were tunneled subcutaneously and anastomosed, in an end-to-end fashion, with cephalic vein at wrist region, and subsequently in a side-artery to end-vein at the elbow crease. The transposed AVFs were created in three patients with ESKD (2M/1F), mean age 47± 3.6 years, (two in the non-dominant arm), without complications. After 4 weeks, all the AVF were patent and the access flow was 660±120 ml/min. All the three AVF was deemed mature and usable for hemodialysis. Conclusion In selected cases, autologous transposition of the cephalic vein can be used to create an AVF, providing a long segment for cannulation. This type of AVF can be an alternative to prosthetic fistula, sparing the central venous catheter.

Endoscopic Endonasal Internal Carotid Artery Transposition Technique in Tumor With Parasellar Extension: A Single-Center Experience.

Lateralization or mobilization of the internal carotid artery (ICA) during a midline approach is required to expose lesions behind or lateral to the ICA. However, there have been no published data regarding the surgical outcomes of the endoscopic endonasal internal carotid transposition technique (EEITT). This study aimed to analyze the relevant surgical anatomy around the ICA and propose a grading scheme of EEITT. A retrospective review of patients who underwent EEITT at a single institution was performed. Based on structures that limited the ICA and intraoperative findings, an anatomically surgical grading scheme of EEITT was proposed. Forty-two patients (mean age 45.6 years, 57.1% female patients) were included. Of them, 29 cases (69.0%) were Knosp grade 4 pituitary adenoma, 6 cases (14.3%) were chordoma, 6 cases (14.3%) were meningioma, and a single case (2.4%) was meningeal IgG4-related disease. The EEITT was categorized into Grades 1, 2 and 3, which was used in 24 (57.1%), 12 (28.6%), and 6 (14.3%) cases, respectively. The most common symptom was visual disturbance (45.2%). The gross total resection rate in Grade 1 (79.2%) and Grade 2 (83.3%) was much higher than that in Grade 3 (66.6%). The overall rate of visual function improvement, preoperative cranial nerve (CN) palsy improvement, and postoperative hormonal remission was 89.4%, 85.7%, and 88.9%, respectively. The rate for the following morbidities was cerebrospinal fluid leakage, 2.4%; permanent diabetes insipidus, 4.8%; new transient CN palsy, 9.5%; permanent CN palsy, 4.7%; panhypopituitarism, 7.1%; and ICA injury, 2.4%. The EEITT is technically feasible and could be graded according to the extent of disconnection of limiting structures. For complex tumor with parasellar extensions, the distinction into Grades 1, 2, and 3 will be of benefit to clinicians in predicting risks, avoiding complications, and generating tailored individualized surgical strategies.

Outcomes of brachial artery transposition in hemodialysis patients

ObjectiveIn hemodialysis patients with a difficult access extremity who are not suitable for an arteriovenous fistula or arteriovenous graft creation, the concept of cannulating a superficialized artery for arterial outflow in dialysis sessions has been adopted as a tertiary alternative. However, its long-term patency and complications have not been recognized widely. We report our 16-year experience with hemodialysis access creation using the brachial artery transposition (BAT) technique. MethodsThis single-center retrospective study included consecutive patients who underwent BAT for hemodialysis vascular access between June 1, 2006, and December 31, 2022. The patency of the whole access circuit and the transposed brachial artery itself was evaluated independently. ResultsIn total, 193 surgical procedures were included. The success rate was 93.2%. The mean operative time was 128 minutes. The median interval from access placement to first cannulation was 21 days. The primary patency rates for BAT were 92.3%, 91.3%, 90.3%, 86.1%, and 71.9% at 1, 2, 3, 5, and 10 years, respectively. The secondary patency rates for BAT were 96.3%, 96.3%, 95.0%, 90.1%, and 74.9% at 1, 2, 3, 5, and 10 years, respectively. The primary patency rates for the whole access circuit were 61.4%, 49.2%, 45.8%, and 26.9% at 1, 2, 3, and 5 years, respectively. The secondary patency rates for the whole access circuit were 85.1%, 83.3%, 82.0%, and 68.6% at 1, 2, 3, and 5 years, respectively. The overall patient survival rates were 79.6%, 69.6%, 54.6%, 36.5%, and 13.4% at 1, 2, 3, 5 and 10 years, respectively. The abandonments of BAT were brachial artery thrombosis (n = 6), pseudoaneurysm (n = 2), aneurysmal change (n = 1), and other reasons (n = 1). The abandonments of the whole access circuit were exhaustion of venous return (n = 26), abandonment of BAT (n = 7), and other reasons (n = 2). Complications were exhaustion of venous return (n = 26), aneurysmal change (n = 12), pseudoaneurysm (n = 6), brachial artery thrombosis (n = 7), impaired wound healing (n = 19), lymphorrhea (n = 9), skin infection (n = 5), hematoma on cannulation (n = 3), and reduced peripheral blood flow (n = 2). ConclusionsThe patency of BAT was excellent, and that of the whole access circuit was adequate, with a few complications. BAT is an effective alternative from a long-term perspective for patients who are unsuitable for conventional hemodialysis access creation.