Vascular Trunk Research Articles

Association between eyeball asymmetry and offset of openings in optic nerve head canal assessed by posterior polar eyeball topography.

We investigated three-dimensional (3D) eyeball protrusion and its association with the offset between the lamina cribrosa (LC) and Bruch's membrane opening (BMO). 3D-MRI scans were taken from 93 subjects (186 eyes). An ellipsoid was fitted along the posterior 2/3 contour of each eyeball. Eyeball asymmetry with focal bulging was determined by the existence of an adjacent outward protrusion/reciprocal inward depression pair, and the angular deviation of the outermost protruded point (OPP) was measured from the nasal side of the fovea-BMO axis. The LC/BMO offset was evaluated by measuring the central retinal vascular trunk (CRVT) location from the BMO center: (1) the angular deviation and (2) the offset index as the ratio between the CRVT-BMO center distance and the BMO radius in the same direction. Seventy-nine eyes (42%) were classified as having eyeball asymmetry, which had a more superior LC/BMO offset (P < 0.001) and a larger offset index (P = 0.002). In those eyes, the angular deviation of the OPP showed a significant correlation with that of the LC/BMO offset (r = -0.724, P < 0.001), as did protrusion depth with the offset index (r = 0.291, P = 0.009). The presence of eyeball asymmetry was associated with superior LC/BMO offset (P = 0.004) and larger offset index (P = 0.009). Superior LC/BMO offset was associated with older age (P < 0.001), shorter axial length (P < 0.001) and inferior location of OPP (P < 0.001). The location and extent of focal bulging were closely associated with those of LC/BMO offset. This indicates that focal bulging during expansion might be associated with diverse directionality of LC/BMO offset.

Optic nerve head factors associated with initial central visual field defect in primary open-angle glaucoma

We investigated optic nerve head factors associated with initial parafoveal scotoma (IPFS) in primary open-angle glaucoma. Eighty (80) patients with an IPFS and 84 patients with an initial nasal step (INS) were compared. Central retinal vascular trunk (CRVT) deviation from the Bruch’s membrane opening (BMO) center was measured as a surrogate of lamina cribrosa (LC)/BMO offset, and its obliqueness was defined as the absolute value of angular deviation from the fovea-BMO axis. Proximity of retinal nerve fiber layer defect (RNFLD) was defined as the angular deviation of the inner RNFLD margin from the fovea-BMO axis. Microvasculature dropout (MvD) was defined as a focal sectoral capillary dropout with no visible microvascular network identified in the choroidal layer. Factors associated with IPFS, as compared with INS, were assessed using logistic regression analyses and conditional inference tree analysis. The IPFS group had more oblique CRVT offset (P < 0.001), RNFLD closer to the fovea (P < 0.001), more MvD (P < 0.001), and more LC defects (P < 0.001) compared to the INS group. In logistic regression analyses, obliqueness of CRVT offset (P = 0.002), RNFLD proximity (P < 0.001), and MvD (P = 0.001) were significant factors influencing the presence of IPFS. Conditional inference tree analysis showed that RNFLD closer to the fovea (P < 0.001) in the upper level, more oblique CRVT offset (P = 0.013) and presence of MvD (P = 0.001) in the lower level were associated with the probability of having IPFS. IPFS was associated with closer RNFLD location to the fovea when assessed from the BMO. Oblique LC/BMO offset may not only mask RNFLD proximity to the fovea due to a deviated funduscopic disc appearance, but also potentiate IPFS via focal LC defect and MvD.

A bicarotid trunk with associated right retroesophageal subclavian artery in a child with neurofibromatosis type 1 complicated by a left hemispheric stroke.

To describe the association between two aortic arch branch variants and its possible relationship with neurofibromatosis-1. A 5-year-old female with NF-1 diagnosis presented to the emergency department at 2months of age with irritability, vomiting and left gaze deviation. Brain MRI showed a left side acute hemispheric stroke and left internal carotid occlusion. CT angiography of the neck showed the right and left common carotid arteries arising from a common vascular trunk coming from the aortic arch and a right retroesophageal subclavian artery. Although the relationship between NF-1 mutation and aortic arch branch abnormalities has not been described, there is a recognized condition known as neurofibromatosis/Noonan syndrome which is an accepted variant of NF-1 with clinical features of both NF-1 and Noonan syndrome caused by dysregulation of the RAS-MAPK pathway. Aortic arch branch variations in patients with NF-1 could be explained by this association.

Hemisphere opposite to central retinal vascular trunk deviation is earlier affected by glaucomatous damage in primary angle-closure glaucoma.

The purpose of the study was to investigate whether the position of the central retinal vascular trunk (CRVT), as a surrogate for lamina cribrosa (LC) offset, is associated with the dominant hemisphere of visual field defect in primary angle-closure glaucoma (PACG) eyes. Central retinal vascular trunkdeviation was measured from Bruch's membrane opening (BMO) centre, which was delineated by OCT imaging, using the horizontal midline as a reference. The dominant hemisphere developing visual field defect was defined as three connected abnormal points (having a p-value < 5% probability of being normal) appearing in only one hemisphere or each point of the hemisphere having a statistically worse value compared with its mirrored point in the opposite hemisphere on pattern deviation plots. One hundred five (80%) of 132 eyes with PACG had dominant hemisphere of visual field defect initially: 70 eyes (67%) in the superior and 35 eyes (33%) in the inferior hemisphere. The CRVT was located superiorly in the dominant superior visual field defect group (p < 0.001). A logistic regression analysis revealed that superior deviation of the CRVT was the only factor associated with dominant superior visual field defect (p < 0.001). Externally oblique border (EOB) presence was associated with larger BMO (p=0.005) and angular deviation of CRVT (p=0.002). Central retinal vascular trunk deviation was associated with the dominant hemisphere of visual field defect in PACG eyes. This finding implies that the LC position relative to the BMO centre (LC/BMO offset) may incur structural vulnerability in the optic nerve head of PACG eyes.

Offset of openings in optic nerve head canal at level of Bruch\u2019s membrane, anterior sclera, and lamina cribrosa

We compared the central retinal vascular trunk (CRVT) position, as a surrogate of lamina cribrosa (LC) offset, with the anterior scleral opening (ASCO) offset from the Bruch’s membrane opening (BMO). Based on the BMO-centered radial scans, the BMO and ASCO margins were demarcated, and each center was determined as the center of the best-fitted ellipse for each margin. The ASCO/BMO offset was defined as the offset between each center. Angular deviations and the extent of ASCO and CRVT offsets from the BMO center were compared directly. Incomplete demarcation of ASCO was found in 20%, which was associated with a larger BMO area and a larger ASCO offset from the BMO. The angular deviation of ASCO offset was associated with that of CRVT offset and that of the longest externally oblique border. The ASCO offset was smaller than the CRVT offset, and, unlike the CRVT offset, it was rarely deviated to the inferior side. The complete ASCO margin might not be demarcatable when determined on BMO-centered radial scans in the presence of an offset. Also, the ASCO, which reflects only the superficial scleral layer, might not reflect the LC position, because the LC might be shifted further from the ASCO.

Central retinal vascular trunk deviation in unilateral normal-tension glaucoma.

To investigate whether the position of the central retinal vascular trunk (CRVT), as a surrogate of lamina cribrosa (LC) offset, was associated with the presence of glaucoma in normal-tension glaucoma (NTG) patients. The position of the CRVT was measured as the deviation from the center of the Bruch's membrane opening (BMO), as delineated by spectral-domain optical coherence tomography imaging. The offset index was calculated as the distance of the CRVT from the BMO center relative to that of the BMO margin. The angular deviation of CRVT was measured with the horizontal nasal midline as 0° and the superior location as a positive value. The offset index and angular deviation were compared between glaucoma and fellow control eyes within individuals. NTG eyes had higher baseline intraocular pressure (P = 0.001), a larger β-zone parapapillary atrophy area (P = 0.013), and a larger offset index (P<0.001). In a generalized linear mixed-effects model, larger offset index was the only risk factor of NTG diagnosis (OR = 31.625, P<0.001). A generalized estimating equation regression model revealed that the offset index was larger in the NTG eyes than in the control eyes for all ranges of axial length, while it was the smallest for the axial length of 23.4 mm (all P<0.001). The offset index was larger in the unilateral NTG eyes, which fact is suggestive of the potential role of LC/BMO offset as a loco-regional susceptibility factor.

A Technique for Absolute Haemostasis

Background . Acute bleeding of parenchymal organs in blunt soft tissue traumas, sharp force injuries, bullet and shrapnel wounds is often life­threatening due to hypoxia combined with haemorrhagic shock. Hypoxia and haemorrhagic shock develop due to a continuous blood outflow from multiple gaping non­contractile blood vessels. A safe and effective organ­preserving surgery in parenchymal haemorrhage has not been developed to date. Materials and methods . A survey of scientific and patent literature has been conducted on techniques for parenchymal bleeding haemostasis based on topical cooling and heating­aided surgical interventions. Sources were mined in the Espacenet, Google Patent, eLibrary, Google Scholar, Web of Science, Scopus and PubMed databases. Results and discussion . An original method for parenchymal bleeding arrest was proposed in Russia at the end of the 20th century. The method is based on a safe transverse organ compression at vascular trunk to provide safe ischemia of the injured organ portion and using topical wound heating to trigger blood clotting. The compression is done with a surgical tool usually used for a gentle gastric or gut constriction. Mechanical compression is applied at a force that ensures a complete constriction of the organ’s blood vessels arresting blood outflow from gaping vessels of the wound. Local hyperthermia of the wound surface is provided by a solid sterile object application with a smooth and slippery surface at +42–45 °C. Ischaemia and heating of the bleeding part of parenchymal organ are halted in 5–15 min. An adequacy criterion for the method is absolute haemostasis. Conclusion . An immediate arrest of blood supply to the wound surface complemented by heating at +42–45°С untill absolute haemostasis has been shown a sole rapid haemostatic technique effective in all forms of parenchymal haemorrhage. The entire peritoneal surface irrigation with 50% glycerol of pH 7.4 at +37–42 °С is advised to prevent postoperative abdominal adhesions at completion of surgery.

Modification of Leriche's operation

Among the major disadvantages of the operation of denudation of the vascular wall according to Eeriehe'y are: 1) the thinning of the vascular wall caused by the operation with a violation of its nutrition, which can lead to sequential rupture and profuse bleeding; 2) compression of the vascular trunk by scar tissue with impaired peripheral circulation and the return of those phenomena for the elimination of which the operation is undertaken.

Relationship between Three-Dimensional Magnetic Resonance Imaging Eyeball Shape and Optic Nerve Head Morphology

To determine if the 3-dimensional (3D) eyeball shape is associated with the positions of the central retinal vascular trunk (CRVT) and the externally oblique border (EOB) in the optic nerve head (ONH). Prospective, cross-sectional study. Fifty-six subjects (112 eyes) with a diagnosis of glaucoma or glaucoma suspect. The eyeball shape on 3D magnetic resonance imaging (MRI) scans was classified according to the dimension of the longest diameter: axial dimension (prolate sphere), group 1; horizontal dimension (horizontally oblate sphere), group 2; and vertical dimension (vertically oblate sphere), group 3. The deviation of the CRVT, as a surrogate of lamina cribrosa (LC) shift, was measured from the center of the Bruch's membrane opening (BMO) demarcated by OCT imaging, with the horizontal midline as 0° and the superior location as a positive value. The angular location of the longest EOB was also measured. Positions of CRVT and EOB according to the 3D eyeball shape. Among 112 eyes, 54 (48%) had a prolate shape (group 1), 23 (21%) had a horizontally oblate shape (group 2), and 35 (31%) had a vertically oblate shape (group 3). The angular deviation of the CRVT differed among the groups: to the nasal side in group 1, to the temporal side in group 2, and along the vertical meridian in group 3. In cases of asymmetric eyeball shape, the CRVT was deviated toward the undergrown side from the overgrown side, regardless of grouping. The angular location of the longest EOB was in the direction opposite to the CRVT position (P < 0.001). A generalized estimating equation analysis revealed that the temporal location of the CRVT was associated with older age (P= 0.001), nasal location of the longest EOB (P < 0.001), and oblate shape of the eyeball (P < 0.001, group 2; P= 0.007, group 3). The position of the CRVT and EOB were associated with the 3D eyeball shape. Considering that infant ONH morphology is highly uniform, various modes of eyeball expansion during growth can result in diverse directionalities of offset between the LC and the BMO in adults.

Hemisphere opposite to vascular trunk deviation is earlier affected by glaucomatous damage in myopic high-tension glaucoma.

PurposeTo investigate whether the position of the central vascular trunk, as a surrogate of lamina cribrosa (LC) shift, is associated with the initial hemisphere of visual field defect in myopic high-tension glaucoma (HTG) eyes.MethodsThe deviation of the central vascular trunk was measured from the center of the Bruch’s membrane opening (BMO), which was delineated by OCT imaging. The angular deviation was measured with the horizontal nasal midline as 0° and the superior location as a positive value. The initial hemisphere developing visual field defect was defined as three connected abnormal points (having a P value with less than 0.5% probability of being normal) appearing in only one hemisphere in pattern deviation plots. If those points were observed in both hemispheres initially, the eye was classified as bi-hemispheric visual field defect.ResultsInitially, 36 eyes (44%) had superior visual field defects, 27 (33%) inferior visual field defects, and 18 (22%) bi-hemispheric visual field defects. After a mean follow-up of 5 years, the number of bi-hemispheric visual field defects had increased to 34 (42%). A logistic regression analysis revealed that inferior deviation of vascular trunk was the only factor associated with initial inferior visual field defect (P = 0.001), while initial bi-hemispheric visual field defects were associated with worse mean deviation at initial visits (P<0.001). A conditional inference tree analysis showed that both the angular deviation (P<0.001) and initial mean deviation (P = 0.025) determined the initial hemispheres developing visual field defect.ConclusionsAlthough both hemispheres were involved as glaucoma progression, the axons on the side counter to the vascular trunk deviation were damaged earlier in HTG. This finding implies the LC shift could add additional stress to axons exposed to high intraocular pressure.

Position of Central Vascular Trunk and Shape of Optic Nerve Head in Newborns.

To investigate the baseline position of the central vascular trunk (CVT) and the characteristics of the optic nerve head (ONH) in newborns. CVT position was evaluated based on fundus images obtained from newborns who had undergone eye-screening examinations. It was then graded according to the optic disc area as follows: grade 1, within central 4%; grade 2, within central 9%; grade 3, within central 16%; grade 4, within central 25%; grade 5, outside central 25% of optic disc area. The direction of the CVT position was determined in cases of grade 2 or more as superior, inferior, nasal, and temporal, relative to the optic disc center. The ovality index and the vertical cup-to-disc ratio were determined as well. In 1000 fundus images from 1000 newborns, 87.1% showed grade 1 (95% confidence interval 84.7-88.8), and 10.7% showed grade 2. The most common CVT direction was central (87.1%, grade 1), followed by nasal (11.0%) and inferior (1.2%). The ovality index was 1.28 ± 0.09 (range, 1.01-1.61). The ONH shape was vertically oval and highly uniform. The average vertical cup-to-disc ratio was 0.29 ± 0.13 (range, 0.00-0.67). The CVT of newborns was located in the central area of the ONH in most cases. The shape of the optic disc was vertically oval, and very similar among the newborns. Considering the high variability of ONH morphology and the diverse location of the CVT in adults, our result suggests that the shape of the ONH and the CVT position might change during eyeball growth.

Laparoscopic right hepatectomy with portal vein reconstruction for hepatocelular carcinoma with tumoral portal vein thrombosis in a cirrhotic patient

Background: Performing a hepatectomy to treat a hepatocarcinoma in a cirrhotic patient is associated with improved survival, but may ba a challenging task due to the risk of postoperative liver failure.[1] The use of the laparosopic approach has been widely adopted as it presents lower mortality and postoperative liver failure rates when compared to the open approach.[2] Nevertheless, the use of the laparoscopic approach to treat hepatocarcinomas with advanced vein thrombosis is rarely reported because of the technical challenges involved.[3] Methods: The video presents a totally laparoscopic right hepatectomy with tumor thrombectomy and portal vein reconstruction to treat a large right liver hepatocarcinoma with tumor thrombosis of the right portal vein extending to the main vascular trunk in a chirrotic patient. Results: Operative time was 500 minutes.Estimated blood loss was 275 mililiters. Patient develooped mild ascitis that was managed with diuretics for one month. Patient was discharged on the tenth postoperative day. Eight months after the procedure he was submitted to a CT-scan that disclosed a patent portal vein and no signs of tumor recurrence. Conclusion: In selected patients, the laparoscopic approach may be an effective technique to treat primary liver tumors even in patients with cirrhosis and advanced portal vein tumour thrombosis.

Effect of propofol on NR2B/CaMKIIα signaling pathway in brain injury induced by hepatic ischemia-reperfusion in preadolescent mice

Objective To evaluate the effect of propofol on subunit 2B-containing N-methyl-D-aspartate receptor(NR2B)/calcium/calmodulin-dependent protein kinaseⅡ alpha (CaMKIIα) signaling pathway in brain injury induced by hepatic ischemia-reperfusion (I/R) in preadolescent mice. Methods Sixty-four healthy clean-grade C57BL/6 mice, aged 2 weeks, weighing 4-6 g, were randomized into 4 groups (n=16 each) using a random number table method: sham operation group (S group), hepatic I/R group (HI/R group), propofol control group (P group), and propofol plus hepatic I/R group (P+ HI/R group). The model of 70% liver I/R injury was established by clamping the left and middle lobe vascular trunk in anesthetized mice.Propofol 20 mg/kg was intraperitoneally injected before operation at 30 min before establishing the model in P and P+ HI/R groups.The equal volume of normal saline was given instead in P and P+ HI/R groups.Eight mice of each group were sacrificed at 6 h of reperfusion, hippocampal tissues were obtained for examination of pathological changes of hippocampal tissues and for determination of neuronal apoptosis (by TUNEL) and expression of NR2B, phosphorylated NR2B (p-NR2B), CaMKⅡα and phosphorylated CaMKⅡα (p-CaMKⅡα) (by Western blot). The remaining 8 mice in each group were used for Morris water maze test at 1 month after establishing the model.Apoptosis index was calculated. Results Compared with group S, the escape latency was significantly prolonged, the percentage of the time of staying at the original platform quadrant was decreased, the expression of p-NR2B and p-CaMKIIα was up-regulated, and apoptosis index was increased in HI/R and P+ HI/R groups (P 0.05). Compared with group HI/R, the escape latency was significantly shortened, the percentage of the time of staying at the original platform quadrant was increased, the expression of p-NR2B and p-CaMKIIα was down-regulated, and apoptosis index was decreased (P<0.05), and the pathological changes of hippocampal tissues were significantly attenuated in group P+ HI/R. Conclusion The mechanism by which propofol reduces brain injury induced by hepatic I/R may be related to inhibiting NR2B/CaMKIIα signaling pathway in preadolescent mice. Key words: Propofol; Liver; Reperfusion injury; Brain injuries; Infant; Receptors, N-methyl-D-aspartate; Calcium-calmodulin-dependent protein kinase type 2

Change of β-Zone Parapapillary Atrophy During Axial Elongation: Boramae Myopia Cohort Study Report 3.

To investigate changes of β-zone parapapillary atrophy (PPA) during axial elongation. Change of β-zone PPA was evaluated by spectral-domain optical coherence tomography (SD-OCT) in myopic children for 2 years, prospectively. Using the infrared images acquired by a fixed scan circle in the glaucoma progression analysis (GPA) mode, the retinal pigment epithelial opening (RPEO) and the clinical disc margin (CDM) were manually delineated. The area and position of β-zone PPA was calculated as the differences from those of the RPEO and CDM, respectively. The β-zone PPA was further differentiated into βBM PPA (β-zone PPA with Bruch's membrane [BM]) and γ-zone PPA (β-zone PPA without BM). The change of β-zone PPA was compared between the first and final visits. The area of β-zone PPA increased in 35 eyes (76%). This increase was associated with RPEO area increase and CDM area decrease. The center of β-zone PPA moved along the direction of vascular trunk dragging, but to a lesser extent. The β-zone PPA enlargement was correlated with the extent of vascular trunk dragging (P = 0.014). In all eyes with β-zone PPA increase, the γ-zone portion had increased. Even in childhood, βBM PPA existed next to their γ-zone PPA in 11 eyes (24%), including 4 eyes that showed increase of both γ-zone and βBM portion during axial elongation. Enlargement of β-zone PPA during axial elongation was affected by the extent and direction of vascular trunk dragging, thus implicating disproportionate growth between the retina and sclera.

Position of Central Retinal Vascular Trunk and Preferential Location of Glaucomatous Damage in Myopic Normal-Tension Glaucoma

To investigate the spatial correlation between the central retinal vascular trunk and the preferential location of glaucomatous damage in myopic normal-tension glaucoma (NTG) eyes. Cross-sectional study. One hundred thirty-seven subjects with myopic NTG (137 eyes). The position of the vascular trunk was measured from the center of the Bruch membrane opening (BMO), which was delineated by optical coherence tomography imaging. The angular deviation was measured, with the horizontal nasal midline as 0° and the superior location as a positive value. The shift index was calculated as the distance of the vascular trunk from the BMO center relative to that of the BMO margin. The angular location of the midpoint of the retinal nerve fiber layer (RNFL) defect was measured from the BMO center. In cases with bi-hemispheric RNFL defects, the angular location was measured for the RNFL defect of larger width. For categorical analysis, hemispheric dominancy was determined if the RNFL defect in one hemisphere was larger than twofold that in the opposite hemisphere. In cases with no dominant hemisphere, the eye was classified as bi-equivalent involvement. The vascular trunk position within the BMO and the location of glaucomatous damage. The moderate- and severe-shift groups (shift index ≥ 0.5) were associated with younger age, longer axial length, smaller angular deviation, and lesser incidence of focal lamina cribrosa (LC) defect. A multiple regression analysis showed a significant correlation between the vascular trunk position and the RNFL defect location (P < 0.001). A logistic regression analysis revealed that the dominant RNFL defect occurred in the opposite hemisphere of the vascular trunk (P < 0.001), and bi-equivalent involvement in both hemispheres was associated with a larger shift index (P= 0.001). A conditional inference tree analysis showed that both the angular deviation (P < 0.001) and the extent of vascular trunk shift (P < 0.001) determined the RNFL defect location. In myopic NTG eyes, the vascular trunk is located in the direction opposite of the RNFL defect with reference to the BMO. Because the vascular trunk is embedded in the LC, this implies that LC shift during axial elongation is associated with greater vulnerability of myopic eyes to glaucomatous damage.

Positional Change of Optic Nerve Head Vasculature during Axial Elongation as Evidence of Lamina Cribrosa Shifting: Boramae Myopia Cohort Study Report 2

To investigate the positional change of central retinal vasculature and vascular trunk to deduce the change in the lamina cribrosa (LC) during axial elongation. Prospective cohort study. Twenty-three healthy myopic children (46 eyes). Participants had undergone a full ophthalmologic examination and axial length measurement every 6 months for 2 years. Using spectral-domain OCT, circle scans centered around the optic disc in the glaucoma progression analysis mode, which enabled capturing of the same positions throughout the entire study period, and enhanced depth imaging of the deep optic nerve head complex were performed. Infrared imaging of the circle scans was used to measure the changes in the angles between the first and final visits. The angle between the major superior and inferior retinal arteries was measured along the circle scan twice: from the center of the circle scan and from the central retinal vascular trunk, respectively. The positional change of the retinal vascular trunk also was measured. Change in vascular angle and position of vascular trunk with axial elongation and associated factors. The vascular angle measured from the center of the circle scan did not change (P= 0.247), whereas the angle measured from the central retinal arterial trunk decreased with axial elongation (P < 0.001). A generalized estimating equation analysis revealed that the factors associated with angle decrease were axial elongation (P= 0.004) and vascular trunk dragging (P < 0.001). The extent of vascular trunk dragging was associated with axial elongation (P < 0.001) and increased border length with marginal significance (P= 0.053), but the extent of dragging could not be explained fully by their combination. The major directionality of dragging was mostly to the nasal side of the optic disc, with large variations among participants. During axial elongation, the retinal vasculature at the posterior pole was unchanged, whereas the position of the central vascular trunk was dragged nasally. Because the central retinal vascular trunk is embedded in the LC, its dragging indicates nasal shifting of the LC, which could explain the vulnerability of myopic eyes to glaucomatous optic neuropathy.

Abstract: 17.00 Freestyle Pedicled Perforator And Propellar Flaps: Anatomic Studies And Clinical Application

INTRODUCTION: Freestyle perforator flaps have been described for soft tissue reconstructions throughout the body. The flaps are designed in accordance to the defect, the surrounding available perforators, and excess regional tissue. Knowledge of the anatomic angiosomes and respective perforators provide a broad spectrum of available pedicled flaps for the reconstructive surgeon. We present our anatomic studies and the clinical application of freestyle perforator flaps in the trunk, head and neck, and limb. MATERIALS AND METHODS: Cadaveric anatomic studies were performed to identify reliable perforators based on individual angiosomes. In clinical cases, perforator-preserving incisions were used without the use of a hand-held Doppler or pre-operative imaging. Freestyle fasciocutaneous perforator flaps were harvested following subfascial identification of the largest perforator(s). Flaps were designed based on the defect size, location of the recipient site, and nearby available tissue. Dissection of the perforator was continued to its main vascular trunk for optimal mobility and rotation of the flap. Flaps were rotated or tunneled for final inset, and those that extended into a tertiary angiosome were supercharged as necessary. RESULTS: From January 2012 to June 2015, 42 patients were reconstructed with freestyle perforator flaps without the aid of handheld Doppler or pre-operative imaging. Donor sites were primarily closed in 83.3% of the cases. Total complication rate was 21.4%, with 7 patients (16.7%) presenting with distal flap necrosis. All healed with re-advancement of the flap or dressings. There were no complete flap losses. All defects were adequately closed with the designed flaps. CONCLUSIONS: Understanding of the anatomic perforasomes throughout the body provides the astute reconstructive surgeon with ample reconstructive options for the use of pedicled flaps. Freestyle perforator flaps are a safe and reliable option for trunk, head and neck, and limb soft tissue reconstruction and do not require the use of handheld Doppler or preoperative imaging.

Exercise, Immune System and Circadian Rhythm

Copyright: © 2015 Boukelia B. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abnormal circadian rhythms have been linked to illnesses such as diabetes, depression [1], bipolar disorder [2], seasonal affective disorder (SAD) [3] and even obesity [4]. Furthermore, circadian rhythms can affect body function and health due to sleep-wake cycles, body temperature [5], hormone release [6], and other important body functions. More recent studies have investigated other performance parameters that have also been found to possess a circadian rhythmicity, such as, stroke volume, cardiac output, blood pressure, vascular blood flow, metabolic rate, sweat rate and trunk flexibility [7].

Significance of preoperative 3D-CT angiography for localization of the femoral artery in complicated THA

BackgroundMajor vascular injury is one of the most devastating complications in total hip arthroplasty (THA). Risk for intraoperative vascular injury is increased when the normal vascular anatomy is distorted by previous surgery or dislocation with displacement. Therefore, an appreciation of the vascular anatomy in relation to the anticipated surgical field is critical to avoid this complication during preoperative assessment for a complicated THA. MethodsPreoperative three-dimensional (3D) CT angiography was performed for 24 complicated THAs when altered vascular anatomy around the acetabulum was suspected. When assessing the CT images, the presence of apparent proliferation of vessels close to the original acetabulum as well as a distance of <10 mm from the artery to the acetabulum was deemed a potential risk factor for intraoperative vascular injury. Additionally, the relationships of clinical characteristics and the presence of these risk factors were analyzed to identify the patient population at risk. ResultsThe incidence of proliferation of collateral vessels was higher in patient groups with proximal femoral migration of 5 cm or more and multiple previous surgeries prior to the index THA. Moreover, in three ankylosed hips, lateral deviation of the main vascular trunk with an artery-acetabulum distance of <10 mm was identified in all cases. ConclusionPreoperative 3D-CT angiography in cases of complicated THA revealed altered vascular anatomy which may increase the risk for intraoperative vascular injuries. Patient characteristics related to the risk for this complication were marked proximal femoral migration, multiple previous surgeries, and hip ankylosis. Preoperative image examination of the vascular anatomy is thought to help reduce the risk of inadvertent vascular injury in these complicated THA cases.

Paraganglioma: case of a complex between vascular trunk location of the tumor

Paraganglioma: case of a complex between vascular trunk location of the tumor