Vascular Shunts Research Articles

Morphometry of basilar artery in population of Gujarat

IntroductionThe basilar artery is a large median vessel responsible for supplying various parts of the brain. The aim of this study was to observe, record and compare variations in basilar artery regarding its length, mid length diameter, level of origin and level of termination. MethodSixty human formalin fixed brain specimens obtained from cadavers donated for the study purpose were under examination in the Dept. of Anatomy, Gov. Medical College, Baroda. The process was undertaken according to the dissection method as per the Cunningham manual. The variation in length and diameter of basilar artery was noted using Digital Vernier calipers. Variation in origin and termination of basilar artery was noted using magnifying glass. ResultsVariation in basilar artery diameter found ranged from min 2.02 mm to max 4.45 mm. Variation in length found ranged from min 20.1 mm to 42.02. In most of the cases basilar artery origin and termination was normal. In 4 cases origin was above the Ponto-Medullary junction and in 3 cases it was below. In 2 cases termination was above the Ponto-Mesencephalic junction and in 1 case it was below. DiscussionThis observation highlight the variations in morphological aspects of the basilar artery, the knowledge of variations would help neurosurgeons safely diagnose, as well as plan and execute vascular bypass and shunting procedures for the treatment of stenosis, aneurysms and arteriovenous malformations in the posterior cranial fossa.

Histological Spectrum of Idiopathic Noncirrhotic Portal Hypertension in Liver Biopsies From Dialysis Patients.

Liver biopsy is performed for various indications in dialysis patients. Being a less-common subset, the hepatic pathology in renal dialysis is not well documented. Idiopathic noncirrhotic portal hypertension (INCPH) is a clinical entity associated with unexplained portal hypertension and/or a spectrum of histopathological vascular changes in the liver. After encountering INCPH and vascular changes of INCPH in 2 renal dialysis patients, we sought to further investigate this noteworthy association. A random search for patients on hemodialysis or peritoneal dialysis with liver biopsy was performed. Hematoxylin and eosin, reticulin, trichrome, and CK7 stains were performed on formalin-fixed, paraffin-embedded tissue sections. Histopathological features were reviewed, and the results were correlated with clinical findings. In all, 13 liver biopsies were retrieved. The mean cumulative duration of dialysis was 50 months (range = 17 months to 11 years). All patients had multiple comorbidities. Indications for biopsy were a combination of abnormal liver function tests (6), portal hypertension (4), ascites (3), and possible cirrhosis (3). Two patients with portal hypertension underwent multiple liver biopsies for diagnostic purposes. All (100%) biopsies showed some histological features of INCPH, including narrowed portal venous lumen (9), increased portal vascular channels (8), shunt vessels (3), dilated sinusoids (9), regenerative nodule (5), and features of venous outflow obstruction (3). No cirrhosis was identified. Liver biopsies from patients on dialysis demonstrate histopathological vascular changes of INCPH. Some (31%) patients present with portal hypertension without cirrhosis. The histological changes may be reflective of underlying risk factors for INCPH in this group.

Ophthalmic findings in Behcet׳s disease: Cases without apparent ocular signs

PurposeTo evaluate the fluorescein angiography and infrared autofluorescence finding in patients with confirmed Behcet׳s disease (BD) but without clinical ocular signs. MethodsIn this prospective, non-interventional case series, montage fluorescein angiography (MFA) and infrared autofluorescence imaging were performed for all patients with confirmed BD but without ocular signs in clinical examination. ResultsFifty BD patients (100 eyes) without clinical ocular manifestations were investigated. In MFA, we found fluorescein angiography (FA) leakage in 22 cases (44%) in both eyes, mostly at the periphery of retina. In infrared autofluorescence, profound changes were found in 43 patients, 86 eyes (86%). Twenty-five patients, 50 eyes (50%), presented retinal vascular branching modifications, straightening, tortuosity, and shunt. ConclusionMFA of retina may be useful in patients with presumed BD for early diagnosis, early treatment, and follow-up of patients.

Embryology and anatomy of intrapulmonary shunts.

Pulmonary vascular shunting poses a major clinical risk. In this brief overview, we discuss the morphological aspects of shunting vessels in the lung, their development, and the regulation of their patency.

320-Row Detector Dynamic 4D-CTA for the Assessment of Brain and Spinal Cord Vascular Shunting Malformations. A Technical Note.

Shunting vascular malformations of the brain and spinal cord are traditionally studied using digital subtraction angiography (DSA), the current gold standard imaging method routinely used because of its favourable combination in terms of spatial and temporal resolution. Because DSA is relatively expensive, time-consuming and carries a risk of silent embolic events and a small risk of transient or permanent neurologic deterioration, a non-invasive alternative angiographic method is of interest. New 320 row-detector CT scanners allow volumetric imaging of the whole brain with temporal resolution up to ≌ 3 Hz. Those characteristics make computed tomography angiography (CTA) an affordable imaging method to study the haemodynamics of the whole brain and can also be applied to the study of limited portions of the spinal cord. The aim of this paper is to make a brief summary of our experience in studying shunting vascular malformation of the brain and spinal cord using dynamic 4D-CTA, explaining the technical details of the studies performed at our institution, and the state-of-the-art major advantages and drawbacks of this new technique. We found that dynamic 4D-CTA is able to depict the main architectural characteristics of previously untreated vascular shunting malformations both in brain and spinal cord (i.e. their main arterial feeders and draining veins) allowing their correct diagnosis and exhaustive classification, limiting the use of DSA for therapeutic purposes.

Arterial spin labeling MRI: clinical applications in the brain.

Visualization of cerebral blood flow (CBF) has become an important part of neuroimaging for a wide range of diseases. Arterial spin labeling (ASL) perfusion magnetic resonance imaging (MRI) sequences are increasingly being used to provide MR-based CBF quantification without the need for contrast administration, and can be obtained in conjunction with a structural MRI study. ASL MRI is useful for evaluating cerebrovascular disease including arterio-occlusive disease, vascular shunts, for assessing primary and secondary malignancy, and as a biomarker for neuronal metabolism in other disorders such as seizures and neurodegeneration. In this review we briefly outline the various ASL techniques including advantages and disadvantages of each, methodology for clinical interpretation, and clinical applications with specific examples.

Variations in the Position and Shape of the Basilar Artery

OBJECTIVE: Anomalies of vertebrobasilar vessels arise as early embryonal developmental deteriorations. The majority of them concern the position, origin and shape of the basilar artery. Therefore the present study was carried out to find out the variations in position and shape of the basilar artery using Magnetic Resonance Imaging and CT Angiography.MATHERIAL AND METHODS: The study included 130 consecutive patients, adults of both sexes, treated in UKC Tuzla. Patients were divided into two groups. In one group (100) were patients without aneurysm in the vertebrobasilar tree, and in the second group (30) patients with aneurysm.RESULTS: Three types of variations in the shape of basilar artery were recorded: those with arched course, S-shaped course, and the straight course type. All the three types are approximately of the same percentage prevalence in the group of subjects without aneurysm in the vertebral-basilar tree, as well as in the group with aneurysm. Basilar artery at 89.33% of respondents was located in medial or in paramedial position.CONCLUSION: Attention is drawn to the practical importance of such variations as a possible source of diagnostic errors during cerebral arteriography. We highlight the morphological aspects of the basilar artery, the knowledge of which would help neurosurgeons safely diagnose, as well as plan and execute vascular bypass and shunting procedures for the treatment of stenosis, aneurysms and arteriovenous malformations.

Salvage of upper extremities with humeral fracture and associated brachial artery injury

BackgroundHumeral fractures with brachial artery injury present a challenge for treating surgeons. Treatment practices vary, including use of vascular shunts, multispecialty teams versus an upper-extremity surgeon, and temporizing external fixation. Our objectives were to describe our treatment approach, to define “absolute ischaemia,” to determine whether to use a vascular shunt, and to identify variables that could improve limb salvage rate. MethodsWe conducted a retrospective study of 38 patients with humeral fracture and brachial artery injury from 1999 through 2012 at a level I trauma centre. Demographic and treatment characteristics were compared between blunt and penetrating injuries and between treatment by multispecialty teams and treatment by an upper-extremity surgeon. We investigated other variables of interest, including immediate internal fixation, shunt use, time to brachial artery repair, and flap coverage. This study focused on immediate limb salvage and not on eventual functional outcomes of the limb or patient satisfaction regarding the extremity. The main outcome measure was salvage versus amputation. ResultsThirty-six upper extremities were successfully salvaged, and two underwent eventual amputation. Immediate internal fixation (33 of 38 patients) did not have an adverse effect on the rate of successful limb salvage (p>.05). Shunt use and treatment by an upper-extremity surgeon were not associated with improved salvage rate (p>.05). The need for flap coverage was significantly associated with failed salvage of the extremity (p=.02). ConclusionsSalvage of the upper extremity with humeral fracture and associated brachial artery injury is not dependent on time to brachial artery repair, shunt use, or specialty of treating surgeon. Immediate internal fixation can be performed without adversely affecting the potential for successful salvage. Flap coverage, which is an indicator of severity of soft-tissue injury, correlates with amputation in these severe injuries. Type of study/level of evidenceTherapeutic III.

The effect of maternal diabetes on feto-placental endothelial cells

s / Placenta 35 (2014) A1eA112 A6 PL4.3. THE EFFECT OF MATERNAL DIABETES ON FETO-PLACENTAL ENDOTHELIAL CELLS Ursula Hiden , Silvija Cvitic , Francisca Diaz , Evelyn JantscherKrenn , Gernot Desoye a Department of Obstetrics and Gynecology, Medical Univeristy of Graz, Graz, Austria; b Institute of Cell Biology, Histology and Embryology, Medical University of Graz, Graz, Austria Gestational diabetes mellitus (GDM) is one of the most frequent pregnancy pathologies. As other types of diabetes and resulting from the obesity epidemic, GDM is a growing problemworldwide. Even by women under good glycaemic control, the maternal diabetic environment causes metabolic derangements in the fetus. Thus, the fetal environment is characterized by hyperglycaemia, hyperinsulinemia, metabolicallyinduced hypoxia and altered levels of growth factors which affect placental and fetal development. Histological studies revealed hypervascularisation and reduced endothelial expression of cell junction molecules in the placenta. Furthermore, placental vessels show altered response to vaso-relaxing agents. These findings indicate changes in placental endothelial functions as a consequence of the diabetic environment in utero. The human placenta is a rich source of primary feto-placental endothelial cells and thus gives a great opportunity to investigate endothelial changes occurring in pregnancy pathologies such as GDM. These primary fetoplacental endothelial cells are well characterized and maintain their phenotype in vitro. Using these human primary feto-placental endothelial cells, we revealed that the intrauterine diabetic environment indeed causes sustainable functional changes in placental endothelial cells. These changes are represented by altered angiogenesis, proliferation and gene expression. We speculate that the endothelial cell phenotype in GDM contributes to altered placental function and may even reflect changes in the fetuses of diabetic mothers. PL5.1. UTERO-PLACENTAL VASCULARIZATION DURING THE FIRST TRIMESTER: WHAT ARE THE NON-INVASIVE IMAGING TOOLS IN 2014? Olivier Morel , Anne-Claire Chabot-Lecoanet , Jie Duan , Estelle Perdiolle-Galet a,b Regional Maternity of University, Nancy, France; b IADI Inserm U947, Nancy, France Introduction: The physiopathology of utero-placental (UP) vascularization development is still partially unknown. Major progresses have been achieved, such as the description of the myometrial vascular shunt. Major endpoints, however, such as the perfusion timing of intervillous space by maternal blood, remain unclear. This review aimed to evaluate available non-invasive imaging techniques of UP vascularization during the first trimester. Methods: literature review from Medline. Results: Until recently, 2D Doppler examination was the reference. However, its poor predictive values make it unusable in clinical practice. 3D Doppler angiography (3DPD), more sensitive to slow flow, now allows to quantify flows directly into the UP unit. The predictive value of this test for the prediction of preeclampsia (PE) and intrauterine growth restriction (IUGR) seems high. However, this technique has two major drawbacks: its dependence on machine settings and the lack of information as to the direction of flow, which makes it impossible to disentangle maternal and fetal flow. Performance could be improved by contrast agents. New MRI sequences (BOLD) seem to allow an early diagnosis of IUGR in animal models. Spatial resolution and motion artifacts are the main limitations of this technique. Conclusion: Over the last decade, two new techniques for UP vascularization study have emerged to complement the classical 2D Doppler: the 3DPD and new angio-MRI sequences that do not require use of contrast. They provide the ability to quantify perfusion signal directly within the UP unit, and may permit in the near future major progresses both for the understanding of the physiology of the UP visualization and for the prediction of PE and IUGR. PL5.2. PLACENTAL STRUCTURE AND FUNCTION IN FETAL GROWTH RESTRICTION AND STILLBIRTH C.P. Sibley , V. Abrahams , S. Girard , L. Higgins , E.D. Johnstone , R.L. Jones , A.E.P. Heazell a Maternal and Fetal Health Research Centre, University of Manchester, Manchester, UK; Yale School of Medicine, Yale,

An indeterminate nodule in the cirrhotic liver discovered by surveillance imaging is a prelude to malignancy.

Surveillance imaging often shows indeterminate lesions in the cirrhotic liver, which may represent early hepatocellular carcinoma (HCC), dysplastic or regenerative nodules, or vascular shunts. The risk of HCC after identification of an indeterminate nodule is not well described. We identified 252 patients with cirrhosis and at least one indeterminate nodule discovered on surveillance imaging over a 4-year period. The incidence of HCC development within 2 years of nodule identification was measured along with baseline risk factors associated with developing HCC. The incidence of HCC in this population was 21% (53 of 252), and risk factors associated with HCC included chronic viral hepatitis, male gender, and low platelet count. The median time from identification of an indeterminate nodule to diagnosis of HCC was 2.7 months. Patients with indeterminate nodules who developed HCC were more likely have to have an indeterminate nodule with arterial enhancement. The 2-year incidence of HCC in the setting of cirrhosis and an indeterminate nodule discovered by surveillance imaging may be as high as one in five persons. Early follow-up imaging, biopsy, or empiric treatment should be considered for those at higher risk. Further, this population is well suited for early detection biomarker and chemoprevention studies.

Platypnoea-orthodeoxia syndrome: more than just a PFO

Summary Platypnea-orthodeoxia syndrome (POS) is a rare condition characterised by episodes of dyspnoea and desaturation when changing from a recumbent to a sitting or standing position, due to a right-to-left shunt through the atrial septum (cardiac POS) or a pulmonary vascular shunt. A consistent finding among patients with cardiac POS is an interatrial communication (patent foramen ovale [PFO] or atrial septal defect [ASD]), but these often-congenital anatomies, alone, do not account for development of massive right-to-left shunt, which frequently occurs later in life leading to severe hypoxaemia. We present the case of an 84-year-old woman known for evolutive right breast carcinoma with successive loco-regional progressions, which over several years, despite local and systemic therapy, eventually invaded the right pectoral muscle, with skin infiltration of the right chest wall and right diaphragmatic paralysis. She subsequently developed rapidly progressive dyspnoea: a cardiac workup including contrast examinations (trans-cranial duplex and trans-thoracic echocardiography) showed a massive intra-cardiac right-to-left shunt, while transoesophageal echocardiography confirmed the presence of a large PFO. Based on these findings, the patient was diagnosed with POS and PFO closure was performed with immediate normalisation of oxygen saturation, and at 6–month follow-up no further episodes of desaturation were reported. The aim of this case discussion was to underline the mechanisms leading to significant right-to-left shunt among patients with PFO, especially when in an upright position, and to elucidate the therapeutic op

High Lung Shunt Fraction in Colorectal Liver Tumors Is Associated with Distant Metastasis and Decreased Survival

PurposeTo assess how intratumoral shunting relates to liver metastasis and to clinical outcome. Materials and MethodsLung shunt fraction (LSF) was calculated from macroaggregated albumin scan after transcatheter injection of radioactive particles in 62 patients with colorectal cancer and liver metastases evaluated for selective internal radiation therapy (SIRT) from May 2007 to August 2012. Assessment was performed of how LSF, liver tumor burden, and systemic chemotherapy relate to survival and the presence of lung metastases. LSF and tumor burden were also assessed in a subset of patients who underwent genetic profiling with SNaPshot analysis. ResultsPatients with higher LSF were more likely to have lung metastases and decreased survival, whereas tumor burden was not associated with these outcomes. Patients with genetic mutations had significantly higher LSF than patients with no mutations. Patients who received chemotherapy before SIRT and had low LSF had the longest survival after SIRT. ConclusionsLSF may be a more robust marker of metastasis than tumor size. Increased LSF secondary to vascular shunting within liver metastasis is an indicator of distant lesions and is associated with decreased survival after SIRT. Intratumoral shunting may provide a conduit for circulating tumor cells to access more remote organs, bypassing filtration by liver parenchyma, and may be an important factor in metastasis from colorectal cancer.

Variations in the Position and Shape of the Basilar Artery

OBJECTIVE: Anomalies of vertebrobasilar vessels arise as early embryonal developmental deteriorations. The majority of them concern the position, origin and shape of the basilar artery. Therefore the present study was carried out to find out the variations in position and shape of the basilar artery using Magnetic Resonance Imaging and CT Angiography. MATHERIAL AND METHODS: The study included 130 consecutive patients, adults of both sexes, treated in UKC Tuzla. Patients were divided into two groups. In one group (100) were patients without aneurysm in the vertebrobasilar tree, and in the second group (30) patients with aneurysm. RESULTS: Three types of variations in the shape of basilar artery were recorded: those with arched course, S-shaped course, and the straight course type. All the three types are approximately of the same percentage prevalence in the group of subjects without aneurysm in the vertebral-basilar tree, as well as in the group with aneurysm. Basilar artery at 89.33% of respondents was located in medial or in paramedial position. CONCLUSION: Attention is drawn to the practical importance of such variations as a possible source of diagnostic errors during cerebral arteriography. We highlight the morphological aspects of the basilar artery, the knowledge of which would help neurosurgeons safely diagnose, as well as plan and execute vascular bypass and shunting procedures for the treatment of stenosis, aneurysms and arteriovenous malformations.

The temporal and spatial development of vascularity in a healing displaced fracture

Underlying vascular disease is an important pathophysiologic factor shared among many co-morbid conditions associated with poor fracture healing, such as diabetes, obesity, and age. Determining the temporal and spatial patterns of revascularization following a fracture is essential for devising therapeutic strategies to augment this critical reparative process. Seminal studies conducted in the last century have investigated the pattern of vascularity in bone following a fracture. The consensus model culminating from these classical studies depicts a combination of angiogenesis emanating from both the intact intramedullary and periosteal vasculature. Subsequent to the plethora of experimental fracture angiography in the early to mid-20th century there has been a paucity of reports describing the pattern of revascularization of a healing fracture. Consequently the classical model of revascularization of a displaced fracture has remained largely unchanged. Here, we have overcome the limitations of animal fracture models performed in the above described classical studies by combining novel techniques of bone angiography and a reproducible murine femur fracture model to demonstrate for the first time the complete temporal and spatial pattern of revascularization in a displaced/stabilized fracture. These studies were designed specifically to i) validate the classical model of fracture revascularization of a displaced/stabilized fracture, ii) assess the association between intramedullary and periosteal angiogenesis and iii) elucidate the expression of VEGF/VEGF-R in relation to the classical model. From the studies, in conjunction with classic studies of angiogenesis during fracture repair, we propose a novel model (see abstract graphic) that defines the process of bone revascularization subsequent to injury to guide future approaches to enhance fracture healing. This new model validates and advances the classical model by providing evidence that during the process of revascularization of a displaced fracture 1) periosteal angiogenesis occurs in direct communication with the remaining intact intramedullary vasculature as a result of a vascular shunt and 2) vascular union occurs through an intricate interplay between intramembranous and endochondral VEGF/VEGF-R mediated angiogenesis.

Endovascular Skills for Trauma and Resuscitative Surgery (ESTARS) course

The management of hemorrhage shock requires support of central aortic pressure including perfusion to the brain and heart as well as measures to control bleeding. Emerging endovascular techniques including resuscitative endovascular balloon occlusion of the aorta serve as potential lifesaving adjuncts in this setting. The Endovascular Skills for Trauma and Resuscitative Surgery (ESTARS) course was developed to provide fundamental endovascular training for trauma surgeons. ESTARS 2-day course incorporated pretest/posttest examinations, precourse materials, lectures, endovascular and open vascular instruments, Vascular Intervention System Trainer endovascular simulator, and live animal laboratories for training and testing. Curriculum included endovascular techniques for trauma; review of wires, sheaths, and catheters; as well as regional vascular injury management. Animal laboratories integrated arterial access, angiography, coil embolization, resuscitative endovascular balloon occlusion of the aorta, control of iliac artery injury, and vascular shunt placement. Students completed a knowledge test (precourse/postcourse) and a summative skills assessment. The test measured knowledge and judgment in vascular injury management as defined in the course objectives. Vascular Intervention System Trainer and animal laboratory were used for final examinations. Subjective performance was graded by expert observers using a global assessment scale and performance metrics. Four pilot ESTARS courses were completed, with four participants each. Knowledge and performance significantly improved after ESTARS. Mean test examination scores increased by 77% to 85%, with a mean change of 9 percentage points [paired t (15) = 7.82, p < 0.0001]. The test was unidimensional (Cronbach's α = 0.67). Technical skill significantly improved for both endovascular simulation and live animal laboratory examinations. All participants passed the live animal laboratory practical examination. The ESTARS curriculum is effective at teaching a basic set of endovascular skills for resuscitation and hemorrhage control to trauma surgeons. ESTARS was confirmed as a stepwise and hierarchical curriculum demonstrating measurable improvements in performance metrics and should serve as a model for future competency-based structured training in endovascular trauma skills.

Application of Temporary Vascular Shunting by Infusion Rubber Tubing for Salvage of the Major Vessel Injuries in Limbs

Application of Temporary Vascular Shunting by Infusion Rubber Tubing for Salvage of the Major Vessel Injuries in Limbs

Damage control strategies in the management of acute injury.

Traumatic injury is the leading cause of death worldwide. The rapid evaluation and correction of injuries in these patients is paramount to preventing uncontrolled decompensation and death. Damage control strategies are a compendium of techniques refined over decades of surgical care that focus on the rapid correction of deranged physiology, control of contamination and blood loss, and resuscitation of critical patients. Damage control resuscitation (DCR) focuses on the replacement of lost blood volume in a manner mimicking whole blood, control of crystalloid administration, and permissive hypotension. Damage control laparotomy controls gastrointestinal contamination and bleeding in the operative suite, allowing rapid egress to the intensive care unit for ongoing resuscitation. Pelvic packing, an adjunct to DCR, provides a means to control hemorrhage from severe pelvic fractures. Temporary vascular shunts restore perfusion, while resuscitation and reconstruction are ongoing. Taken together, these strategies provide the trauma surgeon with a powerful arsenal to preserve life in the transition from injury to the shock trauma room to the intensive care unit.

Unilateral shunt formation with thoracic aortic dissection in a whippet

A three-year-old neutered male whippet was presented with intermittent, exercise-induced paraparesis. Femoral pulses were bilaterally absent. Neurologic examination was suggestive of a thoracolumbar myelopathy. Blood pressure measurements revealed hypotension in both pelvic limbs, hypertension in the right thoracic limb and it was immeasurable in the left thoracic limb. Echocardiography was within reference limits. A clear vascular pulsation was palpable on the right ventral abdominal wall. Computed tomographic angiography revealed a dissection of the aortic wall between the left subclavian artery and the brachiocephalic trunk with subsequent thrombus formation. A shunt between the right internal thoracic, cranial and caudal epigastric arteries to preserve blood flow to the pelvic limbs was visualized. Necropsy was declined by the owner. This is the first case report describing the formation of a unilateral vascular shunt following a thoracic aortic occlusion, which presented as exercise-induced paraparesis.

8:45 AM; Abstract No. 226 - Intratumoral vascular shunts as conduits for circulating tumor cells (CTCS) and clusters for distant metastasis

8:45 AM; Abstract No. 226 - Intratumoral vascular shunts as conduits for circulating tumor cells (CTCS) and clusters for distant metastasis

Blood circulation in the fingers is aggravated after creating a vascular access for dialysis: assessment using skin perfusion pressure

Internal vascular shunts for haemodialysis can cause different complications. One of the most serious complications is steal syndrome, which can result in disturbed peripheral circulation causing finger necrosis and lead to amputation. Thus, prevention of these complications is important. Measurement of skin perfusion pressure (SPP) has been used in various clinical settings, including wound-healing management, and its usefulness has been increasingly unveiled. The present study was undertaken to evaluate changes in haemodynamics after internal shunt creation by measuring SPP of the thumb and the little finger before and after surgery in five patients undergoing shunt surgery using the radial artery and the cephalic vein. The study revealed average changes of −22.8 mmHg in thumb SPP. The change in the thumb was statistically significant (p < 0.05). If the effect of surgery and the threshold for wound healing are taken into account, the present results indicate the necessity to pay extra attention to fingers with extremely low preoperative SPP values. For the prevention of serious disturbances of peripheral circulation (e.g. steal syndrome), routine preoperative SPP measurement seems effective for screening of high-risk patients.