Trunk Level Research Articles

Ascending Geometry After Thoracic Endovascular Aortic Repair for Descending Aortic Dissection

ObjectivesThis study aimed to assess geometry changes of the ascending aorta after thoracic endovascular aortic repair (TEVAR) for descending aortic dissection and identify potential risk factors for diameter and length change. MethodsBetween 04/2009 and 07/2021, 102 patients were treated for acute descending aortic dissections (Type B and non-A non-B) with TEVAR and were included in this analysis. Computed tomography angiographic scans were transferred to a dedicated imaging software and detailed aortic measurements (including length, diameter and area) were taken in multiplanar reconstruction postoperatively, after six months and annually thereafter. ResultsSixty-five (58%) patients were male, with a mean age of 66 (±11). Four (4%) patients were diagnosed with a connective tissue disease. Before TEVAR, 79% of our patients were treated with a mean of 1.5 (±1.2) different classes of antihypertensive medications. This number rose to 98% after TEVAR and 2.7 (±1.0) different antihypertensive drugs. There was no significant change in length, diameter, cross-sectional area, or volume of the ascending aorta during the follow-up of 3 years after TEVAR. Body height was a negative predictor for mean ascending aortic diameter (p-value = -0.013; B = -8.890) and mean aortic diameter at the level of the brachiocephalic trunk (p-value = 0.039; B = -14.763). ConclusionsOur data suggests no significant changes in the ascending aorta following TEVAR of the descending thoracic aorta during mid-term follow-up when under stringent blood pressure medication. Additionally, we did not find any modifiable risk factors for geometry parameter increase.

Variations in origin level of superior mesenteric artery, inferior mesenteric artery, and coeliac trunk in Indian population.

The abdominal aorta is a continuation of the thoracic aorta and gives off the coeliac trunk, superior mesenteric artery, and inferior mesenteric artery. The focus of our study is to evaluate variations in the origin level in the coeliac trunk, superior mesenteric artery, inferior mesenteric artery, and aortic bifurcation in the Indian population and compare with various demographics. The study was retrospective and the local ethics committee approval was taken before starting it. Three hundred patients who were more than 18 years of age and required contrast-enhanced CT studies were included in this. The vertebral origin level of the arteries from the abdominal aorta and aortic bifurcation level was analysed. The most common origin level of the coeliac trunk for both males and females was T12-L1 disc level. The most common origin level of the superior mesenteric artery was L1 upper level. The most common origin level of the inferior mesenteric artery was L3 upper level. The most common level of aortic bifurcation was L4 middle level. There was no statistical difference between the origin of any arteries in males and females in the Indian population. As per our study of the Indian population and the published literature, it is realized that there are significant variations in the origins of the coeliac trunk, superior mesenteric artery, inferior mesenteric artery, and abdominal aorta bifurcation in different populations. This study elaborates on potential anatomical variations in the Indian population, particularly the Mumbai city population. Also, our study compares it to different countries' data and their results in variations found in abdominal aorta branches.

Does long-term drought or repeated defoliation affect seasonal leaf N cycling in young beech trees?

Forest trees adopt effective strategies to optimize nitrogen (N) use through internal N recycling. In the context of more recurrent environmental stresses due to climate change, the question remains of whether increased frequency of drought or defoliation threatens this internal N recycling strategy. We submitted 8-year-old beech trees to 2 years of either severe drought (Dro) or manual defoliation (Def) to create a state of N starvation. At the end of the second year before leaf senescence, we labeled the foliage of the Dro and Def trees, as well as that of control (Co) trees, with 15N-urea. Leaf N resorption, winter tree N storage (total N, 15N, amino acids, soluble proteins) and N remobilization in spring were evaluated for the three treatments. Defoliation and drought did not significantly impact foliar N resorption or N concentrations in organs in winter. Total N amounts in Def tree remained close to those in Co tree, but winter N was stored more in the branches than in the trunk and roots. Total N amount in Dro trees was drastically reduced (-55%), especially at the trunk level, but soluble protein concentrations increased in the trunk and fine roots compared with Co trees. During spring, 15N was mobilized from the trunk, branches and twigs of both Co and Def trees to support leaf growth. It was only provided through twig 15N remobilization in the Dro trees, thus resulting in extremely reduced Dro leaf N amounts. Our results suggest that stress-induced changes occur in N metabolism but with varying severity depending on the constraints: within-tree 15N transport and storage strategy changed in response to defoliation, whereas a soil water deficit induced a drastic reduction of the N amounts in all the tree organs. Consequently, N dysfunction could be involved in drought-induced beech tree mortality under the future climate.

OP19 Extended mesenterectomy is not superior to mesenteric sparing resection in primary ileocolic resection for Crohn’s Disease in terms of postoperative endoscopic recurrence – results of an international randomised controlled trial

Abstract Background Extended mesenteric resection has recently been proposed to improve clinical outcomes after an ileocolic resection (ICR) for Crohn’s disease. The aim of this study was to analyse the clinical relevance of extended mesenteric resection, up to the level of the ileocolic trunk (intervention group), compared to conventional mesenteric sparing resection (control group) with regard to postoperative outcomes in patients undergoing primary ICR for Crohn’s disease. Methods In an international randomised controlled trial (RCT), patients ≥16 years, were assigned 1:1 to either the intervention- or the control-group. The anastomotic technique was standardised (side-to-side stapled). To demonstrate a relevant difference of 25% in postoperative endoscopic recurrence (defined as a modified Rutgeerts score ≥i2b, according to central reading) at 6 months, a minimum of 62 evaluable patients per arm were required. Secondary outcome parameters were postoperative morbidity, histopathological outcomes and use of Crohn’s medication postoperatively. Results In total, of the 129 included patients, 56 (43.3%) were male with a median age of 36 (IQR 22-55). There were no statistically significant differences in baseline characteristics between the two groups. There was no difference in endoscopic recurrence rates between the two groups: 27/62 (43.5%) in the intervention group and 27/64 (42.2%) in the control group, (p=1.0) Fig 1. Median time until endoscopy was 6 months (IQR 6-7). More patients received postoperative medical prophylaxis in the intervention group (28% vs 14%). In the control group, more patients started medication after endoscopy (intervention group 20% vs control group 27%). This resulted in a similar number of patients in both groups being on Crohn’s medication after six months, 48% in the intervention group and 41% in the control group. There was no significant difference in length of resection specimen (median length colon 7cm; ileum 22.5cm), blood-loss or operative time. Overall, a postoperative complication occurred in 28%, with anastomotic leakage in 5 (3.9%). Conclusion This is the first RCT to present data on the effect of extended mesenteric resection during ICR for Crohn’s disease. The results of this study showed no superiority of extended mesenteric resection with regard to endoscopic recurrence or other perioperative outcomes.

Pulmonary vascular stenosis scoring in fibrosing mediastinitis.

This study aims to develop a scoring system for evaluating the degree of pulmonary vascular stenosis in fibrosing mediastinitis (FM). A retrospective single-centre study was conducted on 56 patients with FM in China between April 2014 and August 2021. The involvement of pulmonary vessels in patients with FM was assessed using dual-phase computed tomography pulmonary angiography, and we found that 85.7% of the patients had both pulmonary artery (PA) and vein (PV) involvement. PA involvement was mainly located proximal to both the upper PA and the bilateral basal trunk levels in the lower lungs. The involvement of the superior PV was more common than that of the inferior PV, and the right inferior PV was the least involved. Most of these lesions exhibited moderate or severe stenosis. Additionally, a scoring system for evaluating the degree of pulmonary vascular stenosis was developed. A correlation analysis revealed a negative correlation between the final pulmonary vascular score and the pulmonary arterial pressure, pulmonary vascular resistance, and maximum tricuspid regurgitation velocity. The calculated score of 17.1 was the best cut-off value for the diagnosis of mild and severe pulmonary hypertension (PH). We successfully developed a scoring system for pulmonary vascular stenosis that can be used to evaluate the severity of pulmonary vessel involvement and PH. This scoring system may be relevant in the future development of target-based strategies for percutaneous interventions.

A Comparative Study between Dexmedetomidine, Clonidine and Fentanyl as Adjuvants to Bupivacaine in Ultrasound Guided Supraclavicular Brachial Plexus Block

Introduction: Supraclavicular brachial block is a popular and widely used nerve block technique for perioperative anesthesia and analgesia for upper extremity surgery. The block is performed at level of distal trunks and the origin of divisions, where the brachial plexus is confined to its smallest surface area, thus producing a rapid and reliable block of the plexus. It is the popular technique of anesthesia for upper limb surgeries due to its effectiveness in terms of performance, cost, margin of safety and good post-operative analgesia. It provides rapid onset, dense upper limb anesthesia with a single injection. Materials and Methods: About 90 patients who underwent elective upper limb Orthopaedics surgery during the period of the study were randomly divided into three equal groups of participants each using a computer-based random number generator, i.e., group C, D and F. They were compared for the onset and duration of motor and sensory block and post operative analgesia. Results: Mean onset of sensory and motor block was minimum for fentanyl (7.13 ± 0.94, 9.77 ± 0.82 minutes) followed by dexmedetomidine (7.37 ± 1.06, 11.33 ± 1.61 minutes) and clonidine (8.73 ± 0.98, 12.23 ± 1.57 minutes). Duration of block amongst the three groups showed statistically significant difference, dexmedetomidine (585.13 ± 44.42, 546.07 ± 42.02 minutes) having maximum duration of sensory and motor block followed by clonidine (535.77 ± 32.11, 507.30 ± 33.59 minutes) and minimum for fentanyl (330.03 ± 44.25, 284.67 ± 59.96 minutes). Conclusion: We concluded that adding fentanyl to bupivacaine for supraclavicular brachial plexus block had a faster onset of sensory and motor blockade when compared to dexmedetomidine and clonidine, and dexmedetomidine prolonged the duration of analgesia when compared with clonidine and fentanyl.

Study of Dexmedetomidine as an Adjuvant to Bupivacaine- Lignocaine with Adrenaline in Supraclavicular Brachial Plexusblock

Supraclavicular brachial plexus block is a very popular mode of anesthesia for various upper limb surgeries, as it is easiest and most effective and has good post-operative analgesia. It is carried out at the level of trunks i.e7 at the middle of brachial plexus, resulting in homogenou spread of anesthetic agent throughout the plexus with a fast onset and complete block action.9 Dexmedetomidine, is potent, highly selective α2-adrenoceptor agonist, has been used as an adjuvant during regional and local anesthesia because of rapid onset of action and relatively short half-life up to 2 hours. Objective of Study: To compare the effects of addition of Dexmedetomidine to Bupivacaine- Lignocaine with Adrenaline combination for Supraclavicular brachial plexus block with regards to onset and duration of sensory block, motor block. Quality of anesthesia, analgesia and Adverse reactions if any after taking written informed consent. Observations: Onset of sensory as well as motor blockade in Dexmedetomidine group was earlier when compared to plain bupivacaine-lignocaine adrenalin group. The duration of sensory and motor blockade was significantly increased (p<0.05) in Dexmedetomidine group when compared to another group. With respect to hemodynamic parameters Dexmedetomidine group provided a higher Degree of cardiovascular stability with a lesser incidence of hypotension. Result: There is earlier onset of action and longer duration of sensory; Motor block and Duration of analgesia (sensory block) was prolonged in dexmedetomidine group. Hence it is advisable to add dexmedetomidine as an adjuvant to local anesthetic combinations during supraclavicular block for prolonged anesthesia and to provide better analgesia

Exéresis de timoma gigante adherido al pericardio y pulmón izquierdo

Thymoma is an uncommon condition characterized by being the most frequent neoplasm of the anterior mediastinum. It classically appears as a well-demarcated, lobulated tumor mass encapsulated by a fibrous capsule. A 46-year-old female was diagnosed with thymoma by aspiration biopsy. Surgery was performed through a median sternal incision. The left location of the tumor required the placement of the mammary artery retractor to achieve better exposure. The cancer was freed from adhesions to the pericardium, lung and left pleura. Blood vessel ligation was performed at the level of the left brachycephalic venous trunk, pericardium and in the medial anterior region related to thymic vessels. Total removal of the tumor was achieved with excellent postoperative evolution. Keywords: Chest tumor, thymoma, median sternotomy.

Diagnosis of thoracic outlet syndrome with the lower trunk compression of brachial plexus by high-frequency ultrasonography

BackgroundThoracic outlet syndrome (TOS) with the lower trunk compression of brachial plexus (BP) is difficult to diagnosis. This study aimed to summarize the features of thoracic outlet syndrome (TOS) with the lower trunk compression of brachial plexus observed on high-frequency ultrasonography (HFUS).MethodsThe ultrasound data of 27 patients who had TOS with the lower trunk compression of brachial plexus were collected and eventually confirmed by surgery. The imaging data were compared, and the pathogenesis of TOS was analyzed on the basis of surgical data.ResultsTOS occurred predominantly in females (70.4%). Most cases had unilateral involvement (92.6%), mainly on the right side (66.7%). The HFUS features of TOS can be summarized as follows: (1) Lower trunk compression. HFUS revealed focal thinning that reflected compression at the level of the lower trunk; furthermore, the distal part of the nerve was thickened for edema (Affected side: 0.49 ± 0.12 cm vs. Healthy side: 0.38 ± 0.06, P = 0.009), and the cross-sectional area of brachial plexus cords was markedly greater on the injured side than on the healthy side (0.95 ± 0.08 cm² vs. 0.65 ± 0.11 cm², P = 0.004). (2) Hyperechoic fibromuscular bands behind the compressed nerve (mostly the scalenus minimus muscle). (3) Abnormal bony structures: cervical ribs or elongated transverse processes of the 7th cervical vertebra (C7). Surgical results showed that the etiological factors contributing to TOS were (1) muscle hypertrophy and/or fibrosis (100%) and (2) cervical ribs/elongated C7 transverse processes (20.7%).ConclusionTOS with the lower trunk compression of brachial plexus can be diagnosed accurately and reliably by high-frequency ultrasound.

Role of MRI in diagnosis of pulmonary embolism

BackgroundPulmonary embolism (PE) is considered a serious condition and has clinical challenges in diagnosis. Computed tomography pulmonary angiography (CTPA) is considered the gold standard in PE diagnosis. Contrast-enhanced MRA also has a strong useful role in the diagnosis. Our study aims to assess the role of non-contrast MRA in diagnosis of acute pulmonary embolism compared to either CT pulmonary angiography or contrast enhanced MRA.ResultsIn total, 50 patients with PE confirmed by either CTPA or CE-MRA were included in this study. All patients underwent non-contrast MRPA during the three consecutive days after CTPA or at the same examination setting in CE-MRA. The results were compared and statistically analyzed.The mean age of our study group was 47.80 ± 14.01 years. Males represented 56% (28/50) and females 44% (22/50). The per-vessel sensitivity, specificity and accuracy of non-contrast MRPA reached about 100% for each parameter at the level of the pulmonary trunk, main pulmonary and lobar arteries. At the segmental level, sensitivity, specificity, and accuracy reached about 88%, 100%, and 94%, while at the subsegmental level, about 35%, 100%, and 66% respectively. The overall sensitivity, specificity, and accuracy of non-contrast MRPA regardless of the site were 84%, 100%, and 90% respectively.ConclusionsNon-contrast pulmonary MRA has a high sensitivity and specificity in the diagnosis of PE, especially in proximal pulmonary arteries. So, it can be used as an alternative to the CTA and CE-MRA, especially when the CTA and the use of gadolinium are contraindicated.

Magnetic Resonance Imaging in the Diagnosis of Aortic Wall Elastic Properties Disorders and Its Hemodynamics

Background. Vascular stiffness is an important predictor of cardiovascular disease. The vascular wall biomechanical parameters change not only in patients with genetic disorders of the connective tissue. This means that, regardless of etiology, the early detection of a progressive loss of aortic elasticity is of great clinical importance in preventing the development of severe complications. Assessment of aortic biomechanical parameters using magnetic resonance imaging (MRI) is a new level of visualization for aortic diseases allowing to improve surgical tactics and prevent complications. A number of biomechanical parameters determined by aortic MRI demonstrates the process of its wall remodeling, so their analysis will allow to develope an algorithm for the early diagnosis of aneurysms and the threat of acute aortic syndrome.Objective: using aortic MRI data, to evaluate the aortic biomechanical parameters and hemodynamics at pre- and postoperative stages and their impact on the occurrence of complications and relapses in the long-term period.Material and methods. Between 2020 and 2023, in Petrovsky Russian Scientific Center of Surgery, aortic MRI was performed prospectively before and after surgery in 107 patients with diagnoses of ascending aortic aneurysm (55 patients: 48 (87%) males and 7 (13%) females, mean age 79.4±14.91 years) and DeBakey type I and III aortic dissection, chronic stage (52 patients: 44 (85%) males and 8 (15%) females, mean age 54.32±10.41 years).Results. The quantitative data analysis in the postoperative period showed a decrease in the aortic wall elastic properties in the form of extensibility (0.4 [0.34; 0.54] %/mm Hg in the aneurysm group; 0.5 [0.25; 0.55] %/mmHg in the dissection group) and an increase in stiffness in the form of Young’s modulus (0.6 [0.38; 0.68] MPa in the aneurysm group; 0.5 [0.39; 0.83] MPa in the dissection group). Hemodynamic changes in the dissection group after surgery demonstrated a significant increase in values of maximum velocity in the descending aorta (78.6 [66.24; 130.78] cm/sec) and pressure gradient at the celiac trunk level (2.10 [1.76; 6.84] mm Hg). When assessing the pulse wave velocity parameter in both groups, high values were noted with a tendency to increase after surgery (in the aneurysm group, 7.7 [5.7; 20.3] cm/s before surgery versus 8.7 [6.5; 10.65] cm/s after surgery; in the dissection group, 9.7 [6.8; 12.9] versus 12.7 [7.7; 15.7] cm/s, respectively).Conclusion. Monitoring general hemodynamics and blood flow patterns together with an assessment of the aortic wall elasticity will make it possible to identify patients with borderline aortic dilatation. At the same time, studies of the aortic prosthetic segment are of particular interest. The obtained data on hemodynamic changes occuring at the border of the prosthetic and native segments of the operated aorta can confirm and justify the development of a complication in the form of distal stent graft-induced new entry (dSINE).

Ultrasound measurement of the distance of the phrenic nerve from the brachial plexus at the classic interscalene point and upper trunk: A volunteer-based observational study.

The method of blocking the brachial plexus at the level of the upper trunk has been gaining popularity as a phrenic nerve-sparing alternative for interscalene block. We aimed to measure the distance of the phrenic nerve from the upper trunk and compare it with the distance between the phrenic nerve and the brachial plexus at the classic interscalene point by using ultrasound. In this study, after ethical approval and trial registration, 100 brachial plexus of 50 volunteers were scanned from the emergence of the ventral rami and its course was traced to the supraclavicular fossa. The distance of the phrenic nerve from the brachial plexus was measured at two levels: the interscalene groove along the cricoid cartilage (classic interscalene block point) and from the upper trunk. The presence of anatomical variations of the brachial plexus, the classic traffic light sign, vessels across the plexus, and the location of the cervical oesophagus were also noted. At the classic interscalene point, the C5 ventral ramus was observed to be just emerging or to have fully emerged from the transverse process. The phrenic nerve was identified in 86/100 (86%) of scans. The median (IQR) distance of the phrenic nerve from the C5 ventral ramus was 1.6 (1.1-3.9) mm and that of the phrenic nerve from the upper trunk was 17 (12-20.5) mm. Anatomical variations of the brachial plexus, the classic traffic light sign, and vessels across the plexus were seen in 27/100, 53/100, and 41/100 scans respectively. The oesophagus was consistently located on the left side of the trachea. There was a 10-fold increase in the distance of the phrenic nerve from the upper trunk when compared to that from the brachial plexus at the classic interscalene point.

Portal vein aneurysm-etiology, multimodal imaging and current management.

Portal vein aneurysm (PVA) is a rare vascular abnormality, representing 3% of all venous aneurysms in the human body, and is not well understood. It can be congenital or acquired, located mainly at the level of confluence, main trunk, branches and bifurcation. A PVA as an abnormality of the portal venous system was first reported in 1956 by Barzilai and Kleckner. A review from 2015 entitled "Portal vein aneurysm: What to know" considered fewer than 200 cases. In the last seven years, there has been an increase in the number of PVAs diagnosed thanks to routine abdominal imaging. The aim of this review is to provide a comprehensive update of PVA, including aetiology, epidemiology, and clinical assessment, along with an evaluation of advanced multimodal imaging features of aneurysm and management approaches.

Comparison of In-Vivo and Ex-Vivo Ascending Aorta Elastic Properties through Automatic Deep Learning Segmentation of Cine-MRI and Biomechanical Testing.

Ascending aortic aneurysm is a pathology that is important to be supervised and treated. During the years the aorta dilates, it becomes stiff, and its elastic properties decrease. In some cases, the aortic wall can rupture leading to aortic dissection with a high mortality rate. The main reference standard to measure when the patient needs to undertake surgery is the aortic diameter. However, the aortic diameter was shown not to be sufficient to predict aortic dissection, implying other characteristics should be considered. Therefore, the main objective of this work is to assess in-vivo the elastic properties of four different quadrants of the ascending aorta and compare the results with equivalent properties obtained ex-vivo. The database consists of 73 cine-MRI sequences of thoracic aorta acquired in axial orientation at the level of the pulmonary trunk. All the patients have dilated aorta and surgery is required. The exams were acquired just prior to surgery, each consisting of 30 slices on average across the cardiac cycle. Multiple deep learning architectures have been explored with different hyperparameters and settings to automatically segment the contour of the aorta on each image and then automatically calculate the aortic compliance. A semantic segmentation U-Net network outperforms the rest explored networks with a Dice score of 98.09% (±0.96%) and a Hausdorff distance of 4.88 mm (±1.70 mm). Local aortic compliance and local aortic wall strain were calculated from the segmented surfaces for each quadrant and then compared with elastic properties obtained ex-vivo. Good agreement was observed between Young's modulus and in-vivo strain. Our results suggest that the lateral and posterior quadrants are the stiffest. In contrast, the medial and anterior quadrants have the lowest aortic stiffness. The in-vivo stiffness tendency agrees with the values obtained ex-vivo. We can conclude that our automatic segmentation method is robust and compatible with clinical practice (thanks to a graphical user interface), while the in-vivo elastic properties are reliable and compatible with the ex-vivo ones.

Peculiarities of Perception of Sounds by Children with Speech Disorders and Children with Autism Spectrum Disorder

In this study, an attempt was made to find prognostic parameters that allow finding diagnostic differences between the two most common speech disorders (SD) and autism spectrum disorders (ASD). The aim of the study was to compare the characteristics of the conduction of an audio signal at the level of the cerebral trunk (results of ABR) and the loss in the frequencies of the spoken range of 500-1000-2000-4000 Hz (multi ASSR) of the children with ASD and children with SD. The study involved 495 children aged 2 to 11 years. The experimental group included children with ASD in the amount of 245 people, as well as children with speech disorders 250 people. All children were examined at the Prognoz clinic and, according to the conclusion of the audiologists, had no hearing impairment. The data obtained revealed similarities and differences in the functioning of the auditory pathways in children with ASD and SD. The question of whether this information can be used for differential diagnosis needs further study. It is important that the structures of the brainstem, which determine the quality of the conduction of bioelectrical impulses along the auditory pathways, are formed even before the birth of a child. Thus, already in the first weeks of life, it is possible to identify children at risk, who subsequently have a high probability of developing ASD or SD.

Preoperative assessment of the technical complexity of minimally invasive aortic root repair.

The aim of this study was to assess predictors of technical complexity of minimally invasive aortic root repairs (MIARR) performed through J-shaped mini-sternotomies in patients with aortic root aneurysm. This study included 49 patients with aortic root aneurysm who underwent MIARR via an upper median J-shaped mini-sternotomy between January 2017 and April 2020. Preoperative high-resolution computed tomographic images synchronised with electrocardiography were mandatory for inclusion. Predictors of technical complexity were identified, and a scoring system was created. The correlation between technical complexity and intraoperative/postoperative parameters was explored. There was a significant association between technical complexity and increased procedure time (Spearmen's ρ=-0.45, P=0.001), blood loss (Spearmen's ρ=-0.384, P=0.006), cardiopulmonary bypass time (Spearmen's ρ=-0.301, P=0.035), and postoperative bleeding (Spearmen's ρ=-0.265, P=0.066). The anatomical aorta-sternal relationship (distance of >22.1 mm in the axial plane between the midline of the sternotomy plane and the left coronary), distance between the sternal notch and the aortic valve annulus (>14.5 cm in the sagittal plane), distance between the skin and the left coronary artery (>9.53 cm in the axial plane), obesity (Body Mass Index >30), and-diameter at the brachiocephalic trunk level (>37 mm), were strongly associated with procedural complexity. Overall test accuracy was 75.5%, sensitivity was 73.1%, and specificity 78.3%. Finally, we created an online calculator that surgeons can use to determine the probability of a technically difficult of MIARR based on these factors. This novel scoring system can be used to assess the technical complexity of minimally invasive aortic root repairs and to aid in preoperative planning.

PS-BPR03-9: A CASE OF RENAL JUXTAGLOMERULAR CELL TUMOR THAT WAS PREOPERATIVELY DIAGNOSED BY SELECTIVE RENAL VENOUS SAMPLING

A 26-year-old woman without a family history of hypertension was referred to our hospital for a further examination of juvenile hypertension. At 25 years of age, she had headaches, and hypertension (210/120 mmHg) was first noted. A diagnostic examination to assess the hypertension was performed and she was hypokalemic with serum K 2.9 mEq/L. Moreover, the plasma renin activity (PRA) and plasma renin concentration (PRC) was markedly elevated (18.7 ng/mL/h and 196.3 pg/mL), and plasma aldosterone concentration (PAC) was also elevated (291 pg/mL). A captopril challenge test showed a mildly increased PRA response (15.5 ng/mL/h to 20.3 ng/mL/h), but MR angiography and renogram showed no findings suggestive of renal vascular hypertension. On the other hand, dynamic contrast-enhanced CT showed a small neoplastic lesion (10 mm in diameter) without enhancement in the early phase, but with slight enhancement in the late phase, on the left renal upper pole. We performed renal vein sampling, but no obvious lateralization in PRA was found at the main trunk level of the left and right renal veins (14.0 vs. 14.3 ng/mL/h). Therefore, we performed more selective sampling of the branches of the left renal vein and found that PRA in the upper pole branch of the left renal vein was approximately 3.7 times higher than in the inferior pole branch, the main trunk of the left and right renal veins, and the inferior vena cava (51.5 ng/mL/h vs. 14.0–15.1 ng/mL/h). Based on these results, we made a preoperative diagnosis that the tumor in the upper pole of the left kidney was a juxtaglomerular cell tumor producing renin excessively and decided to perform partial left nephrectomy. Juxtaglomerular cell tumors (JCT) are very rare diseases that primarily occur in adolescents and young adults. Excessive renin secretion from the tumor causes secondary hypertension, and hypokalemia. It has been reported that renal vein sampling, in addition to CT and MRI scans, is useful for preoperative localization of JCT. However, the usual method of sampling only the main trunk of the renal vein fails to detect lateralization of the PRAs in many cases. In the present case, we were able to identify the localization of the tumor by performing sampling of the branches of the renal vein. We herein report on the usefulness of selective renal vein sampling for the preoperative diagnosis of JCT.

Role of noncontrast magnetic resonance pulmonary imaging in diagnosis of pulmonary embolism

Background Pulmonary embolism (PE) is a serious condition and has a clinical dilemma in diagnosis. Computed tomography pulmonary angiography (CTPA) is a gold standard in its diagnosis, but MRI has proven a good role in PE diagnosis. Aim The aim of this work was to evaluate the role of noncontrast magnetic resonance pulmonary angiography (MRPA) imaging in diagnosis of acute PE using CTPA as a gold standard. Patients and methods In total, 25 patients with PE confirmed by CTPA were included in this study. All patients underwent computed tomography angiography and noncontrast MRPA on the same day or within three consecutive days. The results were compared and statistically analyzed. Results The mean age of the study group was 46.4 ± 13.5 years. Females represent 60% (15/25) and males represent 40% (10/25). The per-vessel sensitivity of noncontrast MRPA reached to about 100% with specificity 100% at the level of the main trunk, right and left main pulmonary arteries down to segmental arteries. The sensitivity for right subsegmental branches was 25% and left subsegmental branches was 33.3%. Conclusion The noncontrast MRPA has a reasonable sensitivity and specificity in the diagnosis of PE, especially in major branches. So, it can be used as an alternative to the computed tomography angiography, especially when the computed tomography angiography and the use of gadolinium are contraindicated.

317.9: Report of a Case of Double Arm Transplantation Including Left Shoulder Reconstruction

Introduction: Although arm transplantation was proposed as a therapeutic option in arm amputees, only 14 cases were reported. Objectives: A double arm transplantation including reconstruction of the left shoulder was performed on January 13, 2021 in Lyon (France). We report the results one year after the transplantation. Materials and Methods: The recipient was a 48-years old patient with bilateral amputation at proximal arm level after electric shock in January 1998, who underwent liver transplantation in 2002. He received the grafts from a deceased 35-year old male donor. In the recipient on the right side donor humerus was fixed on the remaining 9 cm-long proximal stump, which was reinforced with the donor fibula in an intra-medullary fashion. On the left side the whole donor humerus including the humeral head was transplanted, with reconstruction of the gleno-humeral joint capsule by performing a suspension ligamentoplasty. On the right side the anastomoses were performed between donor and recipient axillary arteries and veins; on the left side the arterial anastomoses were performed between donor and recipient subclavian arteries and the venous anastomosis between donor subclavian vein and recipient jugular vein; Nervous repair was at the proximal nerve level on the right side and at level of the brachial plexus trunks on the left side. Both deltoid muscles were transplanted: on the right side it was used to assure skin vascularization; on the left side the recipient deltoid muscle was reinserted and the donor one was reported posteriorly with its innervation. Cold ischemia time was 101 minutes on the right side and 133 minutes on the left side. Continuous hemodialysis was performed during the surgical procedure to reduce reperfusion-induced ischemic disorders after revascularization. The immunosuppressive protocol included antithymocyte globulins and tacrolimus, steroids and mycophenolate mofetil. An intensive rehabilitation program was initiated since the first post-operative day. Results: In the first post-operative period partial thrombosis of the venous bypass occurred and an anticoagulant treatment was started with consequent hematoma in the left pectoralis, which was successfully treated with percutaneous drainage.A specific antibiotic therapy was given against Propionibacterium acnes, evidenced in the biopsies performed on the recipient’s bones during the transplantation. Twenty days after transplantation the patient developed a Banff grade 2 acute rejection episode on both arms, which disappeared after IV steroids and clobetasol and tacrolimus creams. The patient suffered neuropathic pain at level of the grafted upper extremities.Twelve months after the procedure, the patient is well and very satisfied. His ability in daily life activities is already equivalent to that with the prostheses. Conclusions: This case seems to confirm that bilateral arm transplantation represents a treatment option in bilateral amputees.

Tiempos de activación muscular frente a una desestabilización en pacientes con enfermedad de Parkinson en etapas iniciales

ObjectivesParkinson's disease (PD) generates a high incidence of falls, however, there is little evidence of instabilities in the initial stages. This investigation sought to compare the muscle activation times in patients with initial PD against a postural disturbance vs. a control group. Materials and methodsThe electromyographic activity (EMG) of 10 patients with PD in early stages (61.3 ±3.8 years) and a control group of 10 adults (62.2 ±3.0 year) was evaluated. The participants were subjected to a surface disturbance, which generated a stabilization response. The test was performed under 2conditions: eyes open (OA) v/s eyes closed (OC). Trunk (spinal erector) and lower extremity (soleus, tibialis anterior, femoral biceps, femoral rectus, adductor magnus, gluteus medius) muscle activation time was analyzed using surface EMG. ResultsThe PD group showed faster response times compared to the control group in the soleus muscle in OC (P=.04). This same muscle showed differences when comparing OA vs. OC only in the PD group (P=.04), showing a shorter response time in the OC condition. When comparing the spinal erector muscle, the PD group showed slower response times in the OA (P=.02) and OC (P=.04) conditions compared to the control group. ConclusionsMuscle activation times show that people with PD respond slower in the trunk muscles, while activation times decrease at the distal level. In the early stages, the slower responses at the trunk level could explain the onset of instability postural in these patients.