Understanding Of Vascular Anatomy Research Articles

Transverse Sinus / Sigmoid Sinus

The transverse sinus(TS)and sigmoid sinus(SS)are common sites for dural arteriovenous fistulas, and an understanding of vascular anatomy is important when developing treatment strategies. In recent years, transarterial embolization, with a liquid embolization material, has become the treatment of choice, preserving the sinus without extensive coil filling of the affected sinus. With this expansion of therapeutic options, we feel that an understanding of the microanatomy has become more important. For example, the exact site where the vein of Labbé joins the TS should be determined. This article focuses on the development and anatomy of the TS and SS and makes points that should be considered when treating dural arteriovenous fistulas.

Embolic Material Migration as the Predominant Contributing Factor to Prognostic Deterioration Following Combined Tumor Resection and Preoperative Embolization.

Introduction Preoperative embolization can potentially facilitate surgical resection of challenging tumors in the intracranial and facial regions; however, its clinical efficacy remains controversial, mainly due to potential morbidity risks. We explored negative factors of the combined treatment of preoperative embolization and tumor resection that affect neurological prognosis. Method This retrospective study used clinical data from 132 consecutive tumors that underwent combined treatment at multiple facilities between January 2016 and May 2021. Basic patient information, tumor characteristics, and treatment details were assessed to identify predictors of deterioration as measured using the modified Rankin scale (mRS) score at three months post-treatment. Results Among the 126 eligible combined treatments, a deterioration in the postoperative mRS score was observed in 19/126 (15.1%). Complications related to embolization and tumor resection occurred in 8/126 (6.3%) and 19/125 (15.2%) of procedures, respectively. Multivariate analyses indicated significant associations between migration of embolic material (adjusted odds ratio 13.80; 95% confidence interval 1.25-152.52; p=0.03), elevated intraoperative blood loss (p=0.04), and deterioration of postoperative mRS score. Embolic material migration was identified as the primary prognostic factor for the deterioration of score. An analysis of 192 procedures, excluding those that exclusively used coils, identified embolization targeting the accessory meningeal artery (p=0.046) and the third segment of the internal maxillary artery (p=0.03) as a risk factor for embolic material migration. Conclusions Embolic material migration is the predominant factor associated with declining neurological outcome that persists into the chronic phase after combined treatment. Given that preoperative embolization is a supplementary treatment option, a thorough understanding of vascular anatomy and striving safe procedure are critical.

Aesthetic Considerations in Extremity Salvage and Reconstruction.

After studying this article, the participant should be able to: 1. Have an in-depth understanding of the functional and aesthetic requirements of lower extremity reconstruction. 2. Describe the considerations for achieving an optimal aesthetic outcome in the primary reconstruction settings. 3. Describe modalities of secondary flap revision for achieving an optimal aesthetic outcome. Significant advancements have been made in the management of lower extremity reconstruction since Dr. Taylor's seminal case in 1973. Improvements in our understanding of vascular anatomy and evolution of microsurgical techniques have allowed for an ever-increasing array of free tissue transfer options for lower extremity reconstruction. The resulting expertise has engendered a paradigm shift toward the reconstructive elevator approach, with increased emphasis on cosmetic results. In the primary setting, aesthetic considerations play an important role in precoverage wound preparation, flap selection, and harvest technique, with the goal of achieving excellent like-with-like reconstruction at the time of initial surgery. Flap selection should be made to best match the three-dimensional architecture of the wound, and take into account the defect thickness, flap thickness, flap composition, and pedicle length. Primary flap thinning and harvest in the superficial fascial plane has been shown to be an effective modality to address excess adiposity and improve contour. Despite these efforts, secondary procedures are often required to optimize the limb's final appearance and functional outcomes, particularly in the foot and ankle region. These include debulking, liposuction, and staged excisions. As the field of limb salvage keeps evolving, aesthetics will continue to play an important role in extremity reconstruction planning and execution.

The APR triangle: A practical zone in the Glissonean approach to laparoscopic anatomical right hepatectomy

An understanding of vascular anatomy is crucial for the safe performance of laparoscopic anatomical liver excision. We discovered a triangular zone during the laparoscopic right liver surgery and termed this zone the APR triangle. The purpose of this study was to determine the probability of the existence of the APR triangle and elucidate its various forms. Analyzed three-dimensional image reconstructions of 66 individuals who underwent liver surgery and calculated the statistics for various types of APR triangles under various grouping settings. The APR triangle was present in the majority of cases, with right hepatic vein trunk type in 68% and right hepatic vein branch type in 21%, respectively. The angle between the right anterior and right posterior hepatic pedicles (AP&PP) was at most between 45 and 90° (74%). There was a 35% chance that at least one of the AP&PP was longer than 2 cm, and a 39% chance that both were. The right posterior pedicle first branch would appear at the bifurcation of AP&PP in 13% only. The APR triangle is objectively present and may represent a practical zone for performing laparoscopic right hepatic anatomical resection more simply and safely.

Creation of Stereo-paired Color Vascular Anatomical Charts Using 3-dimentional Images

Three-dimensional (3D) images of blood vessels in the human body, which are acquired by X-ray computed tomography (CT) and cone-beam CT of Angiography devices, are widely used in medical diagnosis and treatment. Using the 3DCT images of blood vessels, we created stereo-paired color vascular anatomical charts for better understanding of vascular anatomy in clinical settings, patient explanations, and student education. Since it is difficult to distinguish branches of blood vessels that show three-dimensionally complicated running such as cerebral blood vessels, we made it easier to identify them anatomically by color-coding each branch of the blood vessel. Also, by using stereo-paired images, we can see the three-dimensional blood vessel running. In the past anatomical books and vascular anatomy atlas, there was no anatomical chart of the whole body blood vessels that could be color-coded and stereoscopically viewed. We have made it possible to identify blood vessels by the stereoscopic vision of the blood vessels using this stereo-paired color anatomical chart. In addition, this vascular anatomical chart can be additionally revised according to the needs of the clinical and educational settings to be used, and the data can be converted into an electronic file so that it can be easily used in the field of radiological examination or at home through electronic media.

Dual-Image Videoangiography During Intracranial Microvascular Surgery.

Indocyanine green videoangiography (ICG-VA) is a valuable tool to assess vessel and aneurysm patency during neurovascular surgical procedures. However, ICG-VA highlights vascular structures, which appear white over a black background. Anatomic relationships are sometimes difficult to understand at first glance. Dual-image videoangiography (DIVA) enables simultaneous visualization of light and near-infrared fluorescence images of ICG-VA. The DIVA system was mounted on an OPMI Pentero Flow 800 intraoperative microscope. DIVA was used during microsurgical procedures on 5 patients who were operated for aneurysm clipping and superficial temporal artery-middle cerebral artery bypass. DIVA provides real-time simultaneous visualization of aneurysm and vessels and surrounding structures including brain, nerves, and surgical clips. Although visual contrast between vessels and background is higher with standard black-and-white imaging, DIVA makes it easier to understand anatomic relationships between intracranial structures. DIVA also provides better vision of the depth of field. DIVA has the potential to become a widely used intraoperative tool to check patency of intracranial vessels. It should be considered as an adjunct to standard ICG-VA for better understanding of vascular anatomy in relation to surrounding structures and can have an impact on decision making during surgery.

Effects of Tissue Component Volumes on Vascular Resistance in Free Flaps.

Background A successful free flap transfer is achieved, in part, by having a thorough understanding of vascular anatomy and blood flow dynamics. We previously reported that vascular resistance differs by type of free flap. To test the hypothesis that the difference reflects the proportion of tissue components within free flaps, we calculated blood flow and vascular resistance for free flaps in which we determined the volume of each tissue component. Methods Measurements and calculations were made for 40 free flap transfers performed at our hospital: 7 radial forearm flaps, 14 anterolateral thigh flaps, and 19 rectus abdominis myocutaneous flaps. Results The vascular resistance of free flaps was inversely related to the volume of each tissue component. Univariate regression analysis revealed that muscle volume correlated most closely with resistance (r = 0.881), followed by skin (r = 0.622), and fat (r = 0.577). Multiple regression analysis confirmed the relationship between combined muscle and fat volume and resistance (R2 = 0.865). Conclusions A strong inverse correlation exists between vascular resistance and combined muscle and fat tissue volume in flaps. It may be helpful to consider these relationships when making decisions regarding choice of free flap and recipient vessels.

Ultrasound Guidance Does Not Prevent Intracarotid Placement of Central Lines

Ultrasound guidance for all central line placements has been advocated in order to avoid vascular complications and misplacement. Ultrasound without sufficient anatomic knowledge, however, does not guarantee technical safety. We report the case of a 55-year-old woman who presented to the hospital with a right cerebellar stroke and diabetic ketoacidosis. A hospitalist physician placed an ultrasound-guided right internal jugular catheter for fluid resuscitation. The postprocedure chest X-ray image was interpreted as a successful placement of right subclavian catheter (Fig 1, A). A computed tomography angiogram was obtained 2 days later as part of the stroke evaluation. This showed the catheter traversing the jugular vein and entering the common carotid artery retrograde into the aortic arch (Fig 1, B). Vascular surgery was consulted. Because the patient had heparin-induced thrombocytopenia with a platelet count of 30,000, she was taken to surgery for open removal (Fig 2, A). After catheter removal, with distal clamping, there was no bleeding from the carotid artery puncture hole. A small transverse arteriotomy removed a 13-mm × 3-mm well-formed clot (Fig 2, B). The jugular and carotid vessels were both repaired primarily, with good flow maintained (Fig 2, C). The patient recovered without any additional neurologic deficits. Ultrasound guidance alone is not sufficient to prevent vascular complications of central line placement. An understanding of vascular anatomy can help prevent such complications and properly diagnose them on chest X-ray imaging. Open surgical removal prevented embolization of a large pericatheter clot that would have occurred with simple removal.Fig 2Artery exposure, thrombus, and repair. A, CVC exposed; B, thrombus; C, repair.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Evaluating anatomical research in surgery: a prospective comparison of cadaveric and living anatomical studies of the abdominal wall

Cadaveric research has widely influenced our understanding of clinical anatomy. However, while many soft-tissue structures remain quiescent after death, other tissues, such as viscera, undergo structural and functional changes that may influence their use in predicting living anatomy. In particular, our understanding of vascular anatomy has been based upon cadaveric studies, in which vascular tone and flow do not match the living situation. An angiographic analysis of the abdominal wall vasculature was performed using plain film and computed tomography angiography in 60 cadaveric hemi-abdominal walls (from 31 cadavers) and 140 living hemi-abdominal walls (in 70 patients). The deep inferior epigastric artery (DIEA) and all of its perforating branches larger than 0.5 mm were analysed for number, calibre and location. Both large, named vessels and small calibre vessels show marked differences between living anatomy and cadaveric specimens. The DIEA was of larger diameter (4.2 mm versus 3.1 mm, P < 0.01) and had more detectable branches in the cadaveric specimens. Perforators were of greater calibre (diameter 1.5 mm versus 0.8 mm, P < 0.01) and were more plentiful (16 versus 6, P < 0.01) in cadaveric specimens. However, the location of individual vessels was similar. Cadaveric anatomy displays marked differences to in vivo anatomy, with the absence of living vascular dynamics affecting vessel diameters in cadaveric specimens. Blood vessels are of greater measurable calibre in cadaveric specimens than in the living. Consequently, cadaveric anatomy should be interpreted with consideration of post-mortem changes, while living anatomical studies, particularly with the use of imaging technologies, should be embraced in anatomical research.

PR32P EVALUATING ANATOMICAL RESEARCH IN SURGERY: A PROSPECTIVE COMPARISON OF CADAVERIC AND LIVING ANATOMICAL STUDIES OF THE ABDOMINAL WALL

Background: Cadaveric research has widely influenced our understanding of clinical anatomy. However, while many soft‐tissue structures remain quiescent after death, other tissues undergo structural and functional changes that may influence their use in predicting living anatomy. In particular, our understanding of vascular anatomy has been based upon cadaveric studies in which vascular tone and flow do not match the living situation.Methods: An angiographic analysis of the abdominal wall vasculature was performed using plain‐film and computed tomography (CT) angiography in 60 cadaveric and 140 living (70 patients) hemi‐abdominal walls The deep inferior epigastric artery (DIEA) and all of its perforating branches larger than 0.5 mm were analysed for number, calibre and location.Results: Both large, named vessels and small calibre vessels show marked differences between living anatomy and cadaveric specimens. The DIEA was of larger diameter (4.2 mm vs. 3.1 mm, p &lt; 0.01) and had more detectable branches in the cadaveric specimens. Perforators were of greater calibre (diameter 1.5 mm vs. 0.8 mm, p &lt; 0.01) and were more plentiful (16 vs. 6, p &lt; 0.01) in cadaveric specimens. However, the location of individual vessels was similar.Conclusions: Cadaveric anatomy displays marked differences to in‐vivo anatomy, with the absence of living vascular dynamics affecting vessel diameters in cadaveric specimens. Blood vessels are of greater measurable calibre in cadaveric specimens than in the living. Consequently, cadaveric anatomy should be interpreted with consideration of post‐mortem changes, while living anatomical studies, particularly with the use of imaging technologies, should be embraced in anatomical research.

Invited Discussion: Harvesting of forearm perforator flaps based on intraoperative vascular exploration: Clinical experiences and literature review

Advancements in microsurgery and a better understanding of vascular anatomy has allowed for expanding indications for perforators flaps in reconstructive surgery. The use of perforator flaps in the forearm has not become widespread, yet the benefit of sparing a major peripheral artery such as the ulnar or radial is certainly worth considering. The authors present their experience with perforator flaps in the forearm.

Perforator Flaps in Head and Neck Reconstruction

This article attempts to put perforator flaps, as they apply to head and neck reconstruction, into perspective. The importance of existing flaps is emphasized. Specific indications for perforator flaps are highlighted. The deep inferior epigastric artery perforator flap is used as the flap of choice for subtotal glossectomy defects by the authors. The anterolateral thigh flap is the most common flap currently used. Indications for its use are highlighted. Facial artery perforator flaps are introduced, and their roles as local flaps in head and neck reconstruction are highlighted. With our better understanding of vascular anatomy, existing flaps such as the submental flap have been recategorized as perforator flaps. Its role in reconstruction, particularly of lower facial defects, is discussed. Finally the internal mammary artery perforator flap is described and its advantages over the deltopectoral flap and the pectoralis major flap outlined.

A New Classification of Vascularized Flaps in Plastic and Reconstructive Surgery

Advances during the last 15 years in microsurgical technique and in our understanding of vascular anatomy have led to the development of two new branches of plastic and reconstructive surgery. The first is the transfer of free composite flaps with microvascular anastomoses. The second is transposition of island flaps solely on a proximal or distal vascular bundle. Both types of operations require an adequate vascular pedicle to provide sufficient blood circulation for flap viability and survival in the recipient site.

The Cross-Leg Flap Revisited

Although free flaps are currently the gold standard for distal lower extremity reconstruction, situations occasionally arise when alternative methods are needed. We present three cases of cross-leg flaps, which have been modernized with current external fixation technology and current understanding of vascular anatomy. All cross-leg flaps were based on the axial blood supply of the posterior descending subfascial cutaneous branch of the popliteal artery. This axial flap afforded considerable length and well-vascularized tissue. All patients were placed in external fixation devices. Adjacent lower extremity joints were exercised during the period of attachment. There were no major complications or flap failures. All patients were ambulatory postoperatively. We conclude that the cross-leg flap, using external fixation techniques and axially based flaps, can be successfully and expeditiously used to cover defects of the lower extremities.

Analysis of Cutaneous Perfusion: An Aid to Lower Extremity Reconstruction

The use of cutaneous and musculocutaneous flaps has been greatly enhanced by a better understanding of vascular anatomy. Cutaneous vessels reach the skin by three basic pathways: over the muscle layer, through the muscles, and between the muscles. The authors' anatomic investigation of each of these three types of vessels and the clinical application of this information is presented.