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1
Fowler, J. D., and N. M. M. Moens. "The Microvascular Carpal Foot Pad Flap: Vascular Anatomy and Surgical Technique." Veterinary and Comparative Orthopaedics and Traumatology 10, no. 04 (1997): 183–86. http://dx.doi.org/10.1055/s-0038-1632592.
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SummaryThe objectives of the study are to describe the vascular anatomy of the carpal foot pad and to describe the surgical technique for its dissection as a free microvascular flap.Sixteen front legs from ten different dogs weighing from 20 to 30 kg were used for the study. All of the dogs were euthanatized for reason unrelated to the study. Dissection of the carpal foot pad with its dominant arterial and venous pedicle was performed and angiographic studies were performed by injection of barium sulphate and “high detailed” radiography.The vascular anatomy of the carpal foot pad was consistent in all of the dogs. The arterial pedicle arises from the caudal interosseous artery and venous drainage is provided by the cephalic vein. A branch of the ulnar nerve parallels the arterial blood supply and may be included in flap dissection. Surgical dissection of the carpal foot pad flap is relatively straight forward. The length and diameter of the arterial and venous pedicle are appropriate for microvascular anastomosis.The carpal foot pad in the dog represents a viable option for microvascular transfer and reconstruction of weight bearing surfaces.Cadaveric dissection was used to study the vascular anatomy of the carpal foot pad in dogs and to assess its potential use as a free microvascular flap.
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Shteynberg, Aleksandr, Eric Silver, and Nissim Hazkour. "Partial Reconstruction of the Auricle With the Tubed Postauricular Flap: A Case Report and Proposed Innovation for Flap Conditioning." Journal of Craniofacial Surgery 35, no. 2 (2024): e129-e131. http://dx.doi.org/10.1097/scs.0000000000009838.
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The authors present a case of a partial auricular deformity acquired from a human bite that was reconstructed using a 3-stage posterior auricular tubed flap. Helical rim avulsions may be ideally reconstructed with a tubed flap created from lax postauricular soft tissue. During the third stage, division and inset of the inferior pedicle of the flap were complicated by venous congestion. The use of leech therapy and topical nitroglycerin successfully improved flap circulation. Given the occurrence of venous congestion due to a sudden change in flap blood circulation, the authors propose a pedicle compression device to be used in the future that assists with flap conditioning. This physiological delay helps minimize flap ischemia by allowing choke vessels to dilate within, thus increasing flap reliability. Therefore, when the pedicle is divided, improved circulation from the previously inset superior pedicle has been established with a decreased risk of venous congestion and arterial insufficiency.
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MATEV, IVAN. "The Osteocutaneous Pedicle Forearm Flap." Journal of Hand Surgery 10, no. 2 (1985): 179–82. http://dx.doi.org/10.1016/0266-7681_85_90010-5.
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Two patients treated by an osteocutaneous radial island flap with retrograde blood flow are described. Rotation of the flap and its distal vascular pedicle by nearly 180 degrees caused no impairment of the arterial flow, but it may interfere with the venous return through the radial veins, as observed in one of our cases. Therefore, it is safer to include in the skin flap an additional vein, suturing it to a superficial vein in the recipient zone, thus ensuring normal venous flow to the flap as well. The purpose of this paper is to present two patients treated by the use of an osteocutaneous radial artery forearm flap.
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Stein, Michael, and Moein Momtazi. "Bladder Outlet Obstruction as a Cause for Late Total Flap Failure in Pelvic Reconstruction with a VRAM." Journal of Reconstructive Microsurgery Open 03, no. 02 (2018): e55-e57. http://dx.doi.org/10.1055/s-0038-1669453.
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Background A 67-year-old man presented with abrupt failure of a pedicled vertical rectus abdominus myocutaneous (VRAM) flap 13 days postoperatively. Methods The patient underwent pelvic reconstruction with a pedicled VRAM flap following sacral chordoma and abdominoperineal resection. The flap remained well perfused and viable until postoperative day 13, at which point the patient was noted to become systemically unwell with fever, chills, and abdominal pain. This clinically coincided with prompt arterial and venous insufficiency of the VRAM flap. Results Computed tomography of the abdomen was ordered to rule out a pelvic collection and revealed an inflated Foley catheter in the bulbar urethra. This was associated with marked distention of the bladder and bilateral hydronephrosis. Direct compression of the deep inferior epigastric pedicle by the bladder neck was noted. Conclusion The case highlights the importance of considering bladder outlet obstruction and subsequent distention as a cause of pedicle compression and VRAM flap failure following pelvic reconstruction.
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Toia, Francesca, Giovanni Zabbia, Tiziana Roggio, Roberto Pirrello, Adriana Cordova, and Salvatore D'Arpa. "Vascular Grafts and Flow-through Flaps for Microsurgical Lower Extremity Reconstruction." Journal of Reconstructive Microsurgery 33, S 01 (2017): S14—S19. http://dx.doi.org/10.1055/s-0037-1606560.
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Background The use of vascular grafts is indicated in case of insufficient pedicle length or for complex defects involving both soft tissues and vessels. Venous grafts (for both venous and arterial reconstructions) and arterial grafts (arterial reconstruction) can be used. This study retrospectively evaluated the needs for vascular reconstruction and its results in a clinical series of lower limb reconstructions with microsurgical free flaps. Materials and Methods From 2010 to 2015, a total of 16 vascular grafts or flow-through flaps were used in 12 patients out of a total of 150 patients undergoing microsurgical reconstruction (8%). Arterial reconstruction was performed in seven cases (six flow-through flaps, one arterial graft), combined arterial and venous reconstruction in four cases (three vein grafts, one combined venous/arterial graft), and venous reconstruction in one case (one venous graft). The rate of complications and donor-site morbidity related to vascular graft harvest were evaluated. Results Reconstruction was successful in all cases, despite an overall complication rate of 17 and 8% of surgical revision. Donor-site morbidity, subjectively evaluated, was minimal with respect to functional deficits and aesthetic outcome. Indications for the different types of grafts are discussed. Conclusion The use of vascular grafts is needed in a relevant percentage of microsurgical reconstruction cases. Venous and arterial vascular grafts, transient arteriovenous fistulas, and “flow-through” microsurgical flaps showed a safe reconstruction comparable to microsurgical reconstructions without the use of grafts. Donor-site morbidity secondary to vascular graft harvest is minimal, and in almost 70% of cases no additional scars are needed.
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Dzodic, Radan, and Nada Santrac. "In situ preservation of parathyroid glands:advanced surgical tips for prevention of permanent hypoparathyroidism in thyroid surgery." J BUON 22, no. 4 (2017): 853–55. https://doi.org/10.5281/zenodo.4529172.
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Hypoparathyroidism (HPT) is one of the most frequentand severe complications of thyroid surgery. It is caused by intraoperative damage, devascularization or accidental removal of the parathyroid glands (PTGs). The incidence of postoperative HPT is directly proportional to surgery extent and surgeon's experience. After 40 years of experience in thyroid surgery, the first author summarizes the already known surgical steps in thyroid surgery and adds some useful practical tips for in situ preservation of PTGs. Our surgical technique focuses on meticulous capsular dissection and preservation of the middle thyroid, Kocher's vein trunk, as well as vein branches that accompany the posterior branch of the superior thyroid artery and inferior thyroid artery trunk. Ligation of all blood vessels should be as close as possible to the thyroid capsule. Identified PTGs should be de-attached from the thyroid capsule on the vascular pedicle without significant dislocation. PTGs preservation during central neck dissection (CND) can be facilitated by using methylene blue dye for sentinel lymph nodes biopsy. PTGs are not colored in blue, unlike central lymph nodes, which facilitates central neck dissection and reduces the possibility of accidental removal of PTGs. After several thousands of preserved PTGs using this original technique, a total prevalence of permanent HPT in the first author's series is less than 0.5%. Following given key points and recommendations to surgical in situ preservation of PTGs, a surgeon can provide good outcome for patients after total thyroidectomy (with or without central neck dissection), regarding HPT as one of the most severe complications of thyroid surgery.
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Chuong, Brian, Kristopher Katira, Taylor Ramsay, John LoGiudice, and Antony Martin. "Reliability of Long Vein Grafts for Reconstruction of Massive Wounds." Journal of Clinical Medicine 12, no. 19 (2023): 6209. http://dx.doi.org/10.3390/jcm12196209.
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When handling large wounds, zone of injury is a key concept in reconstructive microsurgery, as it pertains to the selection of recipient vessels. Historically, surgeons have avoided placing microvascular anastomosis within widely traumatized, inflamed, or radiated fields. The harvest of vein grafts facilitates reconstruction in complex cases by extending arterial and/or venous pedicle length. To illustrate the utility and fidelity of these techniques, this paper reviews the indications and outcomes for vein grafting in ten consecutive patients at a single tertiary referral center hospital. The case series presented is unique in three aspects. First, there are two cases of successful coaptation of the flap artery to the side of the arterial limb of an arteriovenous loop. Second, there is a large proportion of cases where vein grafts were used to elongate the venous pedicle. In these 10 cases, the mean vein graft length was 37 cm. We observed zero flap failures and zero amputations. Although limited in sample size, these case data support the efficacy and reliability of long segment vein grafting in complex cases in referral centers.
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Libondi, Klaudia, Guido Libondi, Michał Nessler, Maciej Stala, Jarosław Śmieszek, and Anna Chrapusta. "Two-point flap blood glucose measurement for monitoring propeller flap perfusion – a case report." Chirurgia Plastyczna i Oparzenia / Plastic Surgery & Burns 9, no. 2 (2021): 49–52. http://dx.doi.org/10.15374/chpio2021007.
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Monitoring flap perfusion is a helpful method of postoperative care allowing for proper early intervention in and salvage of a flap. The basic means of blood supply monitoring include the assessment of color, warmth, skin tension, and a pin-prick examination. Along with advances in microvascular surgery, methods of flap blood circulation assessment have been also developed. This paper presents the case of a peroneal artery propeller perforator flap for the treatment of a secondary wound resulting from an orthopedic complication of ankle arthrodesis. Blood glucose level (BGL) was used to monitor flap perfusion as an early indicator of possible venous congestion. It is well known that in case of vascular compromise, whether arterial or venous, the flap salvage rate depends on how fast the vascular problem is resolved. Arterial insufficiency is easily detectable, and the arterial flow may be also monitored with minidoppler, however venous insufficiency causes symptoms less dynamically. This fact emphasized the importance of early prediction of venous insufficiency before clinical symptoms appear. It is crucial that the time between pedicle impairment and clinical signs is as short as possible.
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Adrianto, Albertus Ari, Kevin Christian Tjandra, Dwi Adiningsih, Jessica Winoto, and Lydia Kuntjoro. "Case Report: Severe intermittent acute abdominal pain caused by extremely rare case of lienorenal accessory spleen torsion and detorsion: an accurate diagnostic and treatment strategy." F1000Research 12 (November 21, 2023): 1489. http://dx.doi.org/10.12688/f1000research.140837.1.
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Background: Accessory spleen (AS) is a rare condition that usually does not cause any symptoms. However recurrent torsion and detorsion of AS commonly happen in the case of AS with long pedicles. Thus diagnostic and treatment procedure is needed to prevent further complication in this case. Case presentation: An extreme case of an Austronesian 22-year-old college student who presented clinical symptoms of crampy abdominal pain in the left upper quadrant (LUQ) three days before being administered in a hospital. The pain was periodically worsened and relieved for the past year due to recurrent torsion and detorsion of the accessory spleen. Radiologic findings were accessory spleen located in the lienorenalis region with the size of 1.6 x 1.8 x 1.4 cm and the vascular accessory spleen extends from the splenic pedicle to the left splenorenal region. The intraoperative finding was a blackish-brown mass with spongy consistency with 0.5 cm of the pedicle. Conclusion: A combination of USG and CT scan with arterial and venous phase is preferred to diagnose the accessory spleen early. While the findings of the accessory spleen with long pedicle are highly suggested to be treated using modified anti-Trendelenburg 3-port laparoscopic excision of the accessory spleen (LEAS).
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MacQuillan, Anthony, Nigel Horlock, Adriaan Grobbelaar, and Douglas Harrison. "Arterial and Venous Anatomical Features of the Pectoralis Minor Muscle Flap Pedicle." Plastic and Reconstructive Surgery 113, no. 3 (2004): 872–76. http://dx.doi.org/10.1097/01.prs.0000105690.74659.95.
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Murakami, Masami, Keijiro Hori, Yosuke Niimi, Yoji Nagashima, and Hiroyuki Sakurai. "Sensate Reverse Medial Plantar Flap for Reliable Forefoot Reconstruction with Flow-through Anterolateral Thigh Flap." Plastic and Reconstructive Surgery - Global Open 10, no. 12 (2022): e4698. http://dx.doi.org/10.1097/gox.0000000000004698.
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Summary: A reverse medial plantar flap is a major option for reconstructing the plantar forefoot. However, reconstruction of the distal forefoot stretches the vessels, causing tightness, and the skin graft to the donor site adds pressure to the vessel, precipitating venous congestion. We used a reverse medial plantar flap to reconstruct the lateral distal forefoot with a flow-through of the anterolateral thigh (ALT) flap for donor site coverage to maintain physiological and stable blood flow. A 74-year-old woman presented to our hospital with a 20-year history of left forefoot skin tumor. The tumor was resected, and histological examination revealed porocarcinoma in the cystic poroid hidradenoma. Additional excision was performed, and the defect area was covered with a biodegradable artificial dermis. The skin defect of the lateral distal plantar area was reconstructed with a reverse medial plantar flap with a reverse flow Y-V pedicle extension method, and the donor site was reconstructed with an ALT flap interposing the lateral circumflex femoral artery with the transected posterior tibial artery. The flap was completely engrafted without any complications, including arterial ischemia or venous congestion, during or after surgery. A distally based reverse medial plantar flap with a reverse flow Y-V pedicle extension method and flow-through of the ALT flap should be considered for the reconstruction of the lateral distal forefoot with a large defect. This method can maximize flap extension and maintain stable arterial inflow and venous drainage without the major complications of venous congestion.
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Gunawardena, Manuri, Jeffrey M. Rogers, Marcus A. Stoodley, and Michael K. Morgan. "Revascularization surgery for symptomatic non-moyamoya intracranial arterial stenosis or occlusion." Journal of Neurosurgery 132, no. 2 (2020): 415–20. http://dx.doi.org/10.3171/2018.9.jns181075.
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OBJECTIVEPrevious trials rejected a role of extracranial-to-intracranial bypass surgery for managing symptomatic atheromatous disease. However, hemodynamic insufficiency may still be a rationale for surgery, provided the bypass can be performed with low morbidity and patency is robust.METHODSConsecutive patients undergoing bypass surgery for symptomatic non-moyamoya intracranial arterial stenosis or occlusion were retrospectively identified. The clinical course and surgical outcomes of the cohort were evaluated at 6 weeks, 6 months, and annually thereafter.RESULTSFrom 1992 to 2017, 112 patients underwent 127 bypasses. The angiographic abnormality was arterial occlusion in 80% and stenosis in 20%. Procedures were performed to prevent future stroke (76%) and stroke reversal (24%), with revascularization using an arterial pedicle graft in 80% and venous interposition graft (VIG) in 20%. A poor outcome (bypass occlusion, new stroke, new neurological deficit, or worsening neurological deficit) occurred in 8.9% of patients, with arterial pedicle grafts (odds ratio [OR] 0.15), bypass for prophylaxis against future stroke (OR 0.11), or anterior circulation bypass (OR 0.17) identified as protective factors. Over the first 8 years following surgery the 66 cases exhibiting all three of these characteristics had minimal risk of a poor outcome (95% confidence interval 0%–6.6%).CONCLUSIONSProphylactic arterial pedicle bypass surgery for anterior circulation ischemia is associated with high graft patency and low stroke and surgical complication rates. Higher risks are associated with acute procedures, typically for posterior circulation pathology and requiring VIGs. A carefully selected subgroup of individuals with hemodynamic insufficiency and ischemic symptoms is likely to benefit from cerebral revascularization surgery.
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Stoodley, Marcus, Jeffrey Rogers, Manuri Gunawardena, and Michael Morgan. "008 Revascularisation surgery for non-moyamoya symptomatic intracranial stenosis and occlusion." Journal of Neurology, Neurosurgery & Psychiatry 89, no. 6 (2018): A4.3—A5. http://dx.doi.org/10.1136/jnnp-2018-anzan.8.
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IntroductionPrevious trials rejected a role of extracranial-to-intracranial bypass surgery for managing symptomatic atheromatous disease. However, haemodynamic insufficiency may still be a rationale for surgery, provided it can be performed with low morbidity and that patency is robust.MethodsConsecutive patients undergoing bypass surgery for non-moyamoya symptomatic intracranial arterial stenosis and occlusion were retrospectively identified. The clinical course and surgical outcomes of the cohort were evaluated at six-weeks, six-months, and annually thereafter.ResultsBetween 1992 and 2017, 112 patients underwent 127 bypasses. The angiographic abnormality was arterial occlusion in 80% and stenosis in 20%. Procedures were to prevent future stroke (76%) and stroke reversal (24%), with revascularisation using an arterial pedicle graft in 80% and venous interposition graft (VIG) in 20%. A poor outcome (bypass occlusion, new stroke, new neurological deficit, or worsening neurologic deficit) occurred in 8.9% of patients. The risk of poor outcome was significantly lower with arterial pedicle grafts (Odds ratio=0.15), bypass for prophylaxis against future stroke (Odds ratio=0.11), or anterior circulation bypass (Odds ratio=0.17). Over the first eight years following surgery there were no poor outcomes in the 66 cases exhibiting all three of these characteristics.ConclusionProphylactic arterial pedicle bypass surgery for anterior circulation ischemia is associated with high graft patency and low stroke and surgical complication rates. Higher risks are associated with acute procedures, typically for posterior circulation pathology and requiring VIGs. A carefully selected subset of individuals with haemodynamic insufficiency and ischaemic symptoms are likely to benefit from cerebral revascularisation surgery.
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Semichev, Ye V., I. S. Malinovskaya, and D. N. Sinichev. "The vascular channel of the axial flap and the host bed at the earliest period after restricted (not free) transposition." Bulletin of Siberian Medicine 7, no. 4 (2008): 52–59. http://dx.doi.org/10.20538/1682-0363-2008-4-52-59.
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In order to investigate the vascular channel change of the flap and vascular bond formation dynamics in the zone of flap-recipient (host) bed after transposition we worked out an experimental model with different variants of vascular pedicle flap preparation (intact pedicle flap, periarterial, perivenous and combined sympathectomy). The vascular channel was investigated with the help of clinical evaluation and investigation of anatomical macro-micro specimen. Clinical-anatomical finding demonstrates abnormal operation of microcirculatory flap channel after all kinds of vascular wall denervation. It was found out that in any variants of flap transposition conduction, the flap lifting and crippling of surrounding tissues causes unavoidable loss of additional (collateral) blood supply sources and disorder of lymph venous outflow. Conduction of pedicle flap sympathectomy in different variants causes additional abnormalities during integration of complicated tissue complex. Preservation of adventitious membrane of arterial vessels creates the most favorable conditions for flap integration and adaptation.
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Li, Xiang, Manchang Liu, Djahida Bedja, et al. "Acute renal venous obstruction is more detrimental to the kidney than arterial occlusion: implication for murine models of acute kidney injury." American Journal of Physiology-Renal Physiology 302, no. 5 (2012): F519—F525. http://dx.doi.org/10.1152/ajprenal.00011.2011.
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In this study, we compared the traditional murine model with renal pedicle clamp with models that clamped the renal artery or vein alone as well as to a whole body ischemia-reperfusion injury (WBIRI) model. Male C57BL/6J mice underwent either clamping of the renal artery, vein, or both (whole pedicle) for 30 or 45 min followed by reperfusion, or 10 min of cardiac arrest followed by resuscitation up to 24 h. After 30 min of ischemia, the mice with renal vein clamping showed the mostly increased serum creatinine and the most severe renal tubule injury. After 45 min of ischemia, all mice with renal vasculature clamping had a comparable increase in serum creatinine but the renal tubule injury was most severe in renal artery-clamped mice. Renal arterial blood flow was most decreased in mice with a renal vein clamp compared with a renal artery or pedicle clamp. A 30-or 45-min renal ischemia time led to a significant increase in the protein level of interleukin-6, keratinocyte-derived chemokine (KC), and granular colony-stimulating factor in the ischemic kidney, but the KC was the highest in the renal pedicle-clamped kidney and the lowest in the renal vein-clamped kidney. Of note, 10 min of WBIRI led to kidney dysfunction and structural injury, although less than longer time clamping of isolated renal vasculature. Our data demonstrate important differences in ischemic AKI models. Understanding these differences is important in designing future experimental studies in mice as well as clinical trials in humans.
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LEUPIN, P., J. WEIL, and U. BÜCHLER. "The Dorsal Middle Phalangeal Finger Flap." Journal of Hand Surgery 22, no. 3 (1997): 362–71. http://dx.doi.org/10.1016/s0266-7681(97)80403-2.
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The dorsal middle phalangeal finger (DMF) flap is a (neuro)vaseular island flap based on one palmar proper digital artery, its venae comitantes (and/or a separate dorsal vein) and the dorsal branch(es) of the palmar digital nerve. The main nerve supply of the donor finger is left undisturbed. The flap may be raised on a short antegrade, long antegrade or a retrograde pedicle, and used as a free, arterial and/or venous flow-through or neurovascular flap. In a prospective study (mean follow-up of 50 months), the results of 43 DMF flaps were analysed. All flaps survived, retained patency of their vascular pedicles and fulfilled their goals. Neurovascular flaps provided sensate coverage at the S3+ level with static 2-point discrimination values of about 10 mm. Dissection between the proper digital nerve and the rest of the neurovascular bundle induced a 5% incidence of cold intolerance and a 12% occurrence of S3+ hypaesthesia. Advantages, drawbacks and indications of DMF flaps are outlined.
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Trivelato, Felipe Padovani, Daniel Giansante Abud, Alexandre Cordeiro Ulhôa, et al. "Dural arteriovenous fistulas with direct cortical venous drainage treated with Onyx®: a case series." Arquivos de Neuro-Psiquiatria 68, no. 4 (2010): 613–18. http://dx.doi.org/10.1590/s0004-282x2010000400025.
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Dural arteriovenous fistulas (DAVFs) may have aggressive symptoms, especially if there is direct cortical venous drainage. We report our preliminary experience in transarterial embolization of DAVFs with direct cortical venous drainage (CVR) using Onyx®. METHOD: Nine patients with DAVFs with direct cortical venous drainage were treated: eight type IV and one type III (Cognard). Treatment consisted of transarterial embolization using Onyx-18®. Immediate post treatment angiographies, clinical outcome and late follow-up angiographies were studied. RESULTS: Complete occlusion of the fistula was achieved in all patients with only one procedure and injection in only one arterial pedicle. On follow-up, eight patients became free from symptoms, one improved and no one deteriorated. Late angiographies showed no evidence of recurrent DAVF. CONCLUSION: We recommend that transarterial Onyx® embolization of DAVFs with direct cortical venous drainage be considered as a treatment option, while it showed to be feasible, safe and effective.
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Kim, Jun Hyeok, Sungyeon Yoon, Heeyeon Kwon, Deuk Young Oh, Young-Joon Jun, and Suk-Ho Moon. "Safe and effective thrombolysis in free flap salvage: Intra-arterial urokinase infusion." PLOS ONE 18, no. 3 (2023): e0282908. http://dx.doi.org/10.1371/journal.pone.0282908.
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Despite the high success rate in reconstruction using free tissue transfer, flap failure is often caused by microvascular thrombosis. In a small percentage of cases with complete flap loss, a salvage procedure is performed. In the present study, the effectiveness of intra-arterial urokinase infusion through the free flap tissue was investigated to develop a protocol to prevent thrombotic failure. The retrospective study evaluated the medical records of patients who underwent salvage procedure with intra-arterial urokinase infusion after reconstruction with free flap transfer between January 2013 and July 2019. Thrombolysis with urokinase infusion was administered as salvage treatment for patients who experienced flap compromise more than 24 hours after free flap surgery. Because of an external venous drainage through the resected vein, 100,000 IU of urokinase was infused into the arterial pedicle only into the flap circulation. A total of 16 patients was included in the present study. The mean time to re-exploration was 45.4 hours (range: 24–88 hours), and the mean quantity of infused urokinase was 69,688 IU (range: 30,000–100,000 IU). 5 cases presented with both arterial and venous thrombosis, while 10 cases had only venous thrombosis and 1 case had only arterial thrombosis; in a study of 16 patients undergoing flap surgery, 11 flaps were found to have survived completely, while 2 flaps experienced transient partial necrosis and 3 were lost despite salvage efforts. In other word, 81.3% (13 of 16) of flaps survived. Systemic complications, including gastrointestinal bleeding, hematemesis, and hemorrhagic stroke, were not observed. The free flap can be effectively and safely salvaged without systemic hemorrhagic complications using high-dose intra-arterial urokinase infusion within a short period of time without systemic circulation, even in delayed salvage cases. Urokinase infusion results in successful salvage and low rate of fat necrosis.
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Ren, Z.-Y., C.-Q. Wang, Q.-S. Fan, G.-F. Shen, H. Yan, and Z.-T. Wang. "Management of Vascular Defects in Digital Replantation." Journal of Hand Surgery 20, no. 2 (1995): 262–63. http://dx.doi.org/10.1016/s0266-7681(05)80070-1.
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207 cases of digital amputation (261 digits) with vascular defects were replantated during the past two decades. The vascular defect was managed with various methods. 240 digits (92%) survived with good post-operative circulation and recovery of function. The methods of management of arterial defects were as follows: 1) Digital artery transfer from adjacent digits in 25 thumbs and three index fingers. All had survived. 2) Arterial transplantation: in 12 digits, arteries from the contralateral side or from the digits that were unsuitable for replantation were grafted to fill the arterial defects. All of these fingers survived. 3) Vein graft: superficial veins were taken to reconstruct the defects of the digital arteries in 59 digits, with 55 digits surviving and four failing. 4) Ulnar digital arterial flap of the ring finger. This technique was used in four digits with composite artery and soft tissue loss. All the cases survived. 5) Implantation of the arteries into the distal amputation parts. This was done in two digits with no arteries for anastomosis in the distal parts. The management of venous defects was as follows: 1) Transfer of veins from the adjacent digits. Five digits treated with this technique survived well. 2) Vein graft. Six digits survived but one failed. 3) A venous flap was done in six digits and all the digits survived after this procedure. 4) Arterio-venous anastomosis: this was used in 20 digits without suitable veins for anastomosis in replantation of the digit distal to the DIP joint level. 5) Replantation without venous return: a fish-mouth incision and heparin irrigation was used for venous drainage in 19 digits, with survival of 14. 6) The palmar venous system was anastomosed in 84 digits without dorsal veins for suture. 77 digits survived. 7) Venous fascial flap transfer: A composite venous fascial flap was harvested from the adjacent fingers. The flap was turned over on the side close to the injured finger to make an anastomosis of the veins with those in the distal amputated part. A skin graft was placed over the flap without a tie-over dressing. The pedicle was divided 3 weeks later. All the 16 digits with this technique survived well.
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Hammond, Jacob B., Chad M. Teven, Jonathan A. Flug, et al. "The Chimeric Gracilis and Profunda Artery Perforator Flap: Characterizing This Novel Flap Configuration with Angiography and a Cadaveric Model." Journal of Reconstructive Microsurgery 37, no. 07 (2021): 617–21. http://dx.doi.org/10.1055/s-0041-1723824.
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Abstract Background A chimerically configured gracilis and profunda artery perforator (PAP) flap is highly prevalent based on recent computed tomography (CT)-imaging data. The purpose of this study is to further characterize the vascular anatomy of this novel flap configuration and determine the feasibility of flap dissection. Methods To characterize flap arterial anatomy, lower extremity CT angiograms performed from 2011 to 2018 were retrospectively reviewed. To characterize venous anatomy and determine the feasibility of flap harvest, the lower extremities of cadavers were evaluated. Results A total of 974 lower extremity CT angiograms and 32 cadavers were included for the assessment. Of the 974 CT angiograms, majority (966, 99%) were bilateral studies, yielding a total of 1,940 lower extremities (right-lower-extremity = 970 and left-lower-extremity = 970) for radiographic evaluation. On CT angiography, a chimerically configured gracilis and PAP flap was found in 51% of patients (n = 494/974). By laterality, chimeric anatomy was present in 26% of right lower extremities (n = 254/970) and 25% of left lower extremities (n = 240/970); bilateral chimeric anatomy was found in 12% (n = 112/966) of patients. Average length of the common arterial pedicle feeding both gracilis and PAP flap perforasomes was 31.1 ± 16.5 mm (range = 2.0–95.0 mm) with an average diameter of 2.8 ± 0.7 mm (range = 1.3–8.8 mm).A total of 15 cadavers exhibited chimeric anatomy with intact, conjoined arteries and veins allowing for anatomical tracing from the profunda femoris to the distal branches within the tissues of the medial thigh. Dissection and isolation of the common pedicle and distal vessels was feasible with minimal disruption of adjacent tissues. Chimeric flap venous anatomy was favorable, with vena commitante adjacent to the common pedicle in all specimens. Conclusion Dissection of a chimeric medial thigh flap consisting of both gracilis and PAP flap tissues is feasible in a cadaveric model. The vascular anatomy of this potential flap appears suitable for future utilization in a clinical setting.
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Rauff-Mortensen, Andreas, Mette Marie Berggren-Olsen, Hans Kirkegaard, Kim Houlind, and Hanne Birke-Sørensen. "Faster Detection of Ischemia in Free Muscle Transfer When Using Microdialysis." Journal of Reconstructive Microsurgery 36, no. 03 (2019): 228–34. http://dx.doi.org/10.1055/s-0039-3401036.
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Abstract Background Microdialysis is a clinical method used to detect ischemia after microvascular surgery. Microdialysis is easy to use and reliable, but its value in most clinical settings is hampered by a 1- to 2-h delay in the delivery of patient data. This study evaluated the effectiveness of an increase in the microdialysis perfusion rate from 0.3 to 1.0 µL/min on the diagnostic delay in the detection of ischemia. Methods In eight pigs, two symmetric pure muscle transfers were dissected based on one vascular pedicle each. In each muscle, two microdialysis catheters were placed. The two microdialysis catheters were randomized to a perfusion rate of 0.3 or 1.0 µL/min, and the two muscle transfers were randomized to arterial or venous ischemia, respectively. After baseline monitoring, arterial and venous ischemia was introduced by the application of vessel clamps. Microdialysis sampling was performed throughout the experiment. The ischemic cutoff values were based on clinical experience set as follows: CGlucose < 0.2 mmol/L, CLactate > 7 mmol/L, and the lactate/pyruvate ratio > 50. Results The delay for the detection of 50% of arterial ischemia was reduced from 60 to 25 minutes, and for the detection of all cases of arterial ischemia, the delay was reduced from 75 to 40 minutes when the perfusion rate was increased from 0.3 to 1.0 µL/min. After the same increase in perfusion, the detection of 50% of venous ischemia was reduced from 75 to 40 minutes, and for all cases of venous ischemia, a reduction from 135 to 95 minutes was found. Conclusion When using microdialysis for the detection of ischemia in pure muscle transfers, an increase in the perfusion rate from 0.3 to 1.0 µL/min can reduce the detection delay of ischemia.
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Yagi, Shunjiro, Yoshiko Suyama, Kohei Fukuoka, et al. "Analysis of Fat Grafts for Stabilizing Microvascular Pedicle Geometry in Head and Neck Reconstruction." Journal of Reconstructive Microsurgery Open 02, no. 02 (2017): e140-e144. http://dx.doi.org/10.1055/s-0037-1608671.
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Background Even after careful microanastomosis, microsurgeons sometimes encounter unexpected twisting, kinking, and destabilizing mechanical forces. In these cases, a small fat graft is a useful technique for stabilizing the pedicle geometry in free flap transfer. However, few reports have provided the details with an analysis of fat graft use. The use of fat grafts for free flap transfer in head and neck reconstruction was reviewed. Materials and Methods This was a retrospective review of 157 patients (116 men, 41 women; average ± SD age: 64 ± 13.1 years) who had undergone head and neck reconstruction with free flap transfer between 2010 and 2016. We used a fat graft to stabilize pedicle geometry to prevent kinking and other problems. Postoperative thrombosis formation and the use of a fat graft at the pedicle depending on recipient vessel selection and reconstructed site were examined. Results In 23 patients (14.6%), fat grafting was performed to correct pedicle geometry. A fat graft was used at the arterial anastomosis in 13 patients and at the venous anastomosis in 10. There were no significant differences in postoperative thrombosis formation depending on the use of a fat graft. However, fat grafts were more likely to be performed with the superior thyroid artery as a recipient artery and in tongue and/or oral cavity reconstruction. Conclusion A fat graft is a reliable and easy procedure to correct pedicle geometry. However, reconstructive surgeons should consider the use of a fat graft based on the selection of the recipient vessels and the recipient site.
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Matouk, C. C., T. Krings, K. G. Ter Brugge, and R. Smith. "Cement Embolization of a Segmental Artery after Percutaneous Vertebroplasty: A Potentially Catastrophic Vascular Complication." Interventional Neuroradiology 18, no. 3 (2012): 358–62. http://dx.doi.org/10.1177/159101991201800318.
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Serious complications related to percutaneous vertebral augmentation procedures, vertebroplasty and kyphoplasty, are rare and most often result from local cement leakage or venous embolization. We describe an adult patient who underwent multi-level, thoracic percutaneous vertebral augmentation procedures for painful osteoporotic compression fractures. The patient's percutaneous vertebroplasty performed at the T9 level was complicated by the asymptomatic, direct embolization of the right T9 segmental artery with penetration of cement into the radicular artery beneath the pedicle. We review the literature regarding the unusual occurrence of direct arterial cement embolization during vertebral augmentation procedures, discuss possible pathomechanisms, and alert clinicians to this potentially catastrophic vascular complication.
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Yu, Hanxiang, Yanhui Peng, Hongfang Tuo, Chuncheng Wang, Lin Jia, and Wanxing Zhang. "Gallbladder gangrene after percutaneous vertebroplasty, an uncommon presentation of vascular complication: a case report and analysis of the causes." Journal of International Medical Research 49, no. 3 (2021): 030006052110017. http://dx.doi.org/10.1177/03000605211001720.
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We present a case of an 81-year-old man with gallbladder gangrene after percutaneous vertebroplasty (PV) that was successfully treated via laparoscopic cholecystectomy (LC). The patient underwent multilevel, thoracic PV for painful osteoporotic compression fractures. PV performed at the T6 level was complicated by severe abdominal pain owing to direct embolization of the right T6 segmental artery with penetration of bone cement into the radicular artery beneath the pedicle. Cement leakage, especially arterial embolization of cement into the general circulation, is a known potential complication following PV. Serious complications related to PV augmentation procedures, such as vertebroplasty and kyphoplasty, are rare and most often result from local cement leakage or venous embolization. Combined with this case report, we reviewed the literature regarding the unusual occurrence of direct arterial cement embolization during PV and analyzed the causes to alert clinicians to this potentially rare vascular complication.
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Tseng, Charles Y., Patrick O. Lang, Nicole A. Cipriani, and David H. Song. "Pedicle Preservation Technique for Arterial and Venous Turbocharging of Free DIEP and Muscle-Sparing TRAM Flaps." Plastic and Reconstructive Surgery 120, no. 4 (2007): 851–54. http://dx.doi.org/10.1097/01.prs.0000277663.50061.83.
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Schramm, W., N. Einer-Jensen, and G. Schramm. "Direct venous--arterial transfer of 125I-radiolabelled relaxin and tyrosine in the ovarian pedicle in sheep." Reproduction 77, no. 2 (1986): 513–21. http://dx.doi.org/10.1530/jrf.0.0770513.
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Zacharis, Konstantinos, Stavros Kravvaritis, Theodoros Charitos, Eleni Chrysafopoulou, and Anastasia Fouka. "Adnexal torsion during pregnancy: A rare cause of acute abdomen." Hellenic Journal of Obstetrics and Gynecology 18, no. 2 (2019): 49–52. http://dx.doi.org/10.33574/hjog.1731.
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Ovarian torsion is caused by rotation of the ovary or adnexa with the vascular pedicle on its axis resulting in arterial and venous obstruction. Here we report a case of a pregnant woman presented to the emergency department in early second trimester with acute abdomen. History revealed the presence of an ovarian mass detected by ultrasonography 6 months before pregnancy. Sonographic examination showed right adnexal mass with abnormal Doppler velocimetry and thus immediate laparotomy was decided. Right salpingo-oophorectomy was performed and post-operative course of the patient was uneventful. According to this case, adnexal torsion should not be eliminated from differential diagnosis when it comes to pregnant women with acute abdomen.
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Muslimin, Widya Astuti, and Wahyudi Wahyudi. "026. Utilizing Pre-Existing Lacerations for Frontal Bone Fracture Management: A Case Report." JBN (Jurnal Bedah Nasional) 8, no. 2 (2024): 26. http://dx.doi.org/10.24843/jbn.2024.v08.is02.p026.
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Background: Patients with fractures of the frontal bone use the coronal incision approach to expose the anterior cranial vault, including the forehead. The flap allows for widespread exposure of the fractures, facilitating access for the removal of segmental fractures and hematoma evacuation. Maintaining sufficient pedicle width is crucial to reduce the risk of unintentional arterial damage and to ensure proper venous drainage. The objective of this study was to document the surgical approach for segmental fracture removal under a forehead pedicle flap. Case: This case presents a 22-year-old male with moderate traumatic brain injury, who had two lacerations on his forehead and showed an open depressed fracture of the frontal bone after a motor vehicle collision. The patient experienced loss of consciousness and a history of vomiting. Imaging revealed intracerebral hemorrhage in the frontal region and a depressed fracture of the frontal bone. Intraoperative findings revealed the fracture site through the previous laceration incision. The fracture was clearly evaluated by the surgeon using tools to lift the skin between the two incisions. Conclusion: Despite the access for segment fracture removal being conducted through a pre-existing laceration, the patient outcomes were favorable, and no complications were reported.
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Malviya, Dr Manohar K., Dr Sameer Soni, and Dr Dipangi Gupta. "Nitroglycerin transcutaneous patch: boon to salvaging post-operative partial flap necrosis, simple and effective method." Surgical update: International Journal of Surgery and Orthopedics 7, no. 2 (2021): 10–16. http://dx.doi.org/10.17511/ijoso.2021.i02.03.
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Introduction: The majority of surgical complications after tissue transfer surgery (Localtransposition of the fasciocutaneous flap, Pedicle flap, Free flap or musculocutaneous flap) arerelated to vascular thrombosis, which usually occurs within 3 days of surgery. Venous congestionusually results in oedema and darkening of the skin colour. During early venous obstruction, aneedle stick will cause rapid bleeding of dark blood and arterial obstruction or spasm will causedelayed bleeding. Patients and methods: This is prospective study was carried out during theperiod from January 2018 to February 2021 at the Plastic surgery unit-Chirayu Medical College AndHospital Bhopal, India. This study included patients aged 13 to 70 years undergoing reconstructivesurgery with flaps (Fasciocutaneous Pedicle flap, Free flap, local transposition flap ormusculocutaneous flap) for the wounds at any part of the body. The NTG patch was applied over thecutaneous surface of the compromised flap and then flap insufficiency was observed. Results: Inthis study total of 50 patients with flaps reconstruction were included. Among which 34 %( 17patients) had skin changes and 66 % (33 patients) had congested bleed on needle prick. NTGpatches were applied on the flap surface at regular intervals. After 1 week follows up, the changes in82% (41) flaps were reversed back and the flap remained healthy. 18% (nine) flaps had partial andor complete necrosis. Conclusion: There was a marked reduction in partial flap necrosis in patientswho received nitroglycerin patch. The flap survival was significantly improved and prevents the re-exploration of flaps. Their application is a simple, safe, and effective way to help salvage the flaps.
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Fioravanti, Alex, Luiz Borges, Chelsea Snider, and Guilherme Barreiro. "The Boomerang Thigh Flap: Optimizing the Donor Site for an Extended Skin Island Flap." Journal of Reconstructive Microsurgery 34, no. 08 (2018): 658–68. http://dx.doi.org/10.1055/s-0038-1667130.
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Background The anterolateral region of the thigh is one of the most used donor areas for flaps. However, there are cases in which large defects require more than the conventional skin island provided by the anterolateral thigh flap (ALT). For an extended skin island flap, we developed a new boomerang thigh flap (BTF), in which a boomerang design includes perforators from multiple branches of the lateral circumflex femoral artery (LCFA), providing a single-pedicle, large, reproducible, and reliable flap. We report the anatomical study and the use of the new BTF in a clinical series. Methods We dissected 20 flaps in fresh cadavers to determine the anatomical landmarks, vascular pedicle pattern, perforator distribution, and BTF flap dissection technique. After achieving a reproducible and reliable technique, with primary closure of the donor site based on the pinch test, the BTF was applied for microsurgical reconstructions in the head and neck, lower limb, and upper limb regions. Results The BTF corresponds to a 45° confluence of the ALT and the tensor fascia lata (TFL) elliptical skin islands. It includes the perforators from the transverse/ascending and the descending branches of the LCFA , which conjoined into a single arterial LCFA pedicle in 85% (17) of the cadaver dissections. All the venous branches drained into a single lateral circumflex femoral vein. ALT perforator distribution followed literature descriptions, while TFL perforators were mainly septocutaneous and projected into a virtual rectangle of 6 × 4 cm at the lateral margin of the TFL. Average BTF dimensions were 40 × 8.6 cm. For the clinical cases, flap dimensions and pedicle characteristics were equivalent to the anatomical findings. The BTF was separated into two skin islands in four cases and no major complications were reported. Conclusion The BTF is a reliable, reproducible, and divisible flap that provides extended skin island for reconstruction of large defects.
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Anuradha, Vinjamuri, Prashanth Venkateswaran, Manasa Pandith P.C., and Puneet Shirbur. "Ultrasonography and Magnetic Resonance Imaging in Ovarian Torsion - A Retrospective Study in Hoskote." Journal of Evidence Based Medicine and Healthcare 8, no. 11 (2021): 648–52. http://dx.doi.org/10.18410/jebmh/2021/127.
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BACKGROUND Ovarian torsion occurs when the ovary twists on its fibrovascular pedicle resulting in vascular compromise. Initially, there is twisting of the ovary, fallopian tube, or both structures, causing venous, lymphatic and arterial compromise with resultant ovarian oedema and adnexal enlargement. We wanted to determine the most common ultrasonography (USG) and magnetic resonance imaging (MRI) findings in surgically proven cases of ovarian torsion. METHODS We present a series of cases obtained on retrospective review of USG and MRI findings in 10 surgically proven cases of ovarian torsion between June 2018 to June 2020 in the Department of Radiology, MVJ Medical College & Research Hospital, Hoskote. RESULTS Significant enlargement of the ovary with size ranging from 5 to 15 cms with peripherally displaced follicles and free fluid in the pelvis in noted in all the patients on USG and MRI. Other common MRI features include ‘twisted vascular pedicle’ sign seen in 7 (70 %) cases, areas of haemorrhage within the ovarian stroma in 7 (70 %) cases and abnormal ovarian enhancement in 9 (90 %) cases. CONCLUSIONS Ultrasound and MRI are the main diagnostic imaging modalities prior to treatment. Improved detection and characterisation of pelvic mass contributes to better diagnostic accuracy. The most common findings in US and MRI features of ovarian torsion include ovarian enlargement with peripherally displaced follicles and free fluid in pelvis. Other common MRI features include ovarian haemorrhage, twisted vascular pedicle, abnormal ovarian enhancement and deviation of the uterus towards the same side. KEYWORDS Ovarian torsion, USG, MRI
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Baytinger, V. F., and K. V. Selianinov. "Fatal complications in reconstructive plastic surgery and ways of their prevention." Issues of Reconstructive and Plastic Surgery 24, no. 3-4 (2022): 7–29. http://dx.doi.org/10.52581/1814-1471/78-79/01.
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The world experience and experience of the Institute of Microsurgery (Tomsk, Russia) in rescuing dying free flaps are summarized in the paper. The issues related to the prevention of vascular disorders, which in 85–95% of cases lead to fatal complications in the form of total necrosis of the reperfused flap, are discussed. We are talking about the immediate, early and late complications due to the compromise of blood flow along the vascular pedicle (arterial, venous, arterial-venous). Unlike irreversible disorders, temporary disturbances in blood supply in free flaps are caused by the consequences of primary ischemia and reperfusion. Their duration and reversibility depend on the tissue composition, i.e. from the anoxic resistance of the tissues constituting the flap and, of course, the structures that form the wall of the flap vessels themselves. With a short duration of primary ischemia (up to 1 hour) and compensated reperfusion syndrome, temporary vascular disorders are manifested by flap skin flushing and metabolic edema of its tissues, which disappear 10-40 minutes after reperfusion. The indications for revision of the vascular pedicle are doubts about the adequacy of blood flow in the flap due to the appearance of the first signs of anastomotic thrombosis. The highest rates of flap rescue are achieved after revision of the vascular pedicle no later than 90 minutes after the first signs of thrombosis appear. It is important that the surgeon performing these microvascular anastomoses does the revision. The development of technologies for rescuing a perishing flap has become especially relevant in the last decade. This is due to the rapid development of reconstructive microsurgery of head and neck tumors. In such patients, there is practically no alternative to free transplantation of tissue complexes for the reconstruction of the lower jaw, tongue, soft tissue defect of the lower face and neck. The main technical problem leading to fatal complications after transplantation of a radial, peroneal, anterolateral femur flap is the difficulty of finding recipient vessels suitable for revascularization in soft tissues previously exposed to radiation. The search for alternative recipient vessels during the primary reconstruction of defects, for example, in the oral cavity, is accompanied by a significant increase in the duration of primary ischemia (up to 3–4 hours) and the death of flaps. The preservation of the viability of such free flaps is possible only by their temporary extracorporeal perfusion with extracorporeal membrane oxygenation. It is possible to preserve the viability of free flaps for 2 weeks (without microvascular anastomoses) during tertiary reconstruction of head and neck defects by continuous extracorporeal perfusion of the flap until it is completely engrafted in the recipient area. There is experience of using a tubular non-free radial flap on the long vascular pedicle of the radial vascular bundle (from the wrist to the ulnar fossa) in tertiary tissue reconstruction after removal of head and neck tumors.
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Semple, John L. "Retrograde Microvascular Augmentation (Turbocharging) of a Single-Pedicle TRAM Flap Through a Deep Inferior Epigastric Arterial and Venous Loop." Plastic and Reconstructive Surgery 93, no. 1 (1994): 109–17. http://dx.doi.org/10.1097/00006534-199401000-00016.
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Sośnik, H., and K. Sośnik. "Renal vascularisation anomalies in the Polish population. Coexistence of arterial and venous anomalies in the vascular pedicle of the kidney." Folia Morphologica 78, no. 2 (2019): 290–96. http://dx.doi.org/10.5603/fm.a2018.0079.
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Suh, Young Chul, Joon Pio Hong, and Hyunsuk Peter Suh. "Elevation Technique for Medial Branch based Superficial Circumflex Iliac Artery Perforator flap." Handchirurgie · Mikrochirurgie · Plastische Chirurgie 50, no. 04 (2018): 256–58. http://dx.doi.org/10.1055/a-0631-9180.
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AbstractAccording to early studies on the superficial circumflex iliac artery perforator flap, there are two major types of perforators that are presumed to originate from the superficial circumflex iliac artery: the medial perforator with a direct cutaneous vessel (superficial branch) - located relatively medially on the flap, and the lateral perforator, traveling laterally beneath the deep fascia and often with an intramuscular pathway penetrating the deep fascia on the lateral aspect (deep branch) of the flap. Although there are well described studies on the anatomy of the arterial vasculature, design and elevation of the flap are different issues, as there are always some potential for anatomical variations, such as pedicle anatomy, location of lymph nodes, and thickness of superficial fascia. The presence of internal pudendal artery and superficial inferior epigastric artery in the groin may add to the confusion. One should also beware of the presence of major lymphatics which are drained into the superficial venous system. Therefore this paper will try to simplify the elevation technique based on the medial perforator. However, one must always be ready to identify a good perforator and to elevate it as a freestyle approach to overcome the variations wherever the perforator may originate from. The best way to feel comfortable using any flap is from practice and repetitive elevation. The same is for the medial branch based SCIP flap. The direct cutaneous nature of the pedicle will make the dissection even easier as the dissection course bypasses muscle and lymph nodes. This technical note describes practical surgical tips for elevating the medial perforator based SCIP flap.
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Kozusko, Steven, and Uzoma Gbulie. "Detecting Microsurgical Complications with ViOptix Tissue Oximetry in a Pediatric Myocutaneous Free Flap: Case Presentation and Literature Review." Journal of Reconstructive Microsurgery Open 03, no. 01 (2018): e8-e12. http://dx.doi.org/10.1055/s-0038-1626728.
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Background Microvascular compromise from arterial or venous occlusion is a common cause of free flap failure. The salvage rate following a microvascular compromise is dependent on detecting the problem early and intervening quickly. Methods The ViOptix tissue oximeter measures tissue oxygen saturation using the near-infrared spectroscopy technology. The ViOptix device has an alarm capability to warn of potential compromise to tissue perfusion. The tissue oximetry readings are visible on the bedside monitor and are relayed to a webpage link, which is accessible on a personal computer or mobile device, allowing real-time monitoring. This article presents a case where real-time monitoring allowed almost immediate detection of inadvertent pedicle compromise allowing flap salvage by repositioning without surgical intervention. Results In the case presented, the patient's nurse inadvertently positioned a pillow under the location of the vascular pedicle likely causing microvascular compression. The ViOptix reading dropped and for this reason the nurse contacted the Plastic Surgery team. The drop was confirmed remotely and the flap was urgently evaluated in person. Once the pillow was removed, the ViOptix readings normalized and Doppler signals strengthened in the flap. Discussion While tissue oximetry monitoring does not by itself ensure flap survival, it provides critical information than conventional flap monitoring would allow giving the microsurgeon the opportunity to make a quicker decision. ViOptix tissue oximeters are able to detect vascular compromise even before conventional clinical symptoms are present. Alas in several cases by the time clinical symptoms develop the flap may be beyond salvage.
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Sbitany, Hani, Rachel Lentz, and Merisa Piper. "The “Dual-Plane” DIEP Flap: Measuring the Effects of Superficial Arterial and Venous Flow Augmentation on Clinical Outcomes." Journal of Reconstructive Microsurgery 35, no. 06 (2019): 411–16. http://dx.doi.org/10.1055/s-0038-1677013.
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Background Deep inferior epigastric perforator (DIEP) flaps are routinely elevated on a single dominant perforator from the deep epigastric vascular system. However, the single perforator may not always perfuse an entire flap adequately, particularly suprascarpal tissue. We often perform “dual-plane” single perforator DIEP flaps by rerouting the superficial (SIEA/V) system directly into a branch of the deep (DIEA/V) vascular system pedicle, thus allowing both systems to contribute and enhance flap perfusion. Methods A prospectively collected database of patients undergoing microvascular breast reconstruction was reviewed for patients undergoing “dual-plane” DIEP flaps. These were matched to a similar cohort of patients undergoing “traditional” single perforator DIEP free flaps over the same time period. Treatment demographics and flap-specific morbidity outcomes were assessed, including performance in the setting of radiation. Results Over 2 years, 23 “dual-plane” DIEP flaps were performed (15 patients), compared with 35 single-perforator “traditional” DIEP flaps (23 patients). Rates of delayed healing were similar between both cohorts (2.9 vs. 4.3%, p = 0.28). Rates of palpable fat necrosis were significantly lower in “dual-plane” DIEP flaps compared with “traditional” flaps (0 vs. 14.3%, p = 0.03). Rates of clinically palpable fat necrosis following radiation were significantly lower in the “dual-plane” flaps (4.3 vs. 40%, p = 0.02). Conclusion The “dual-plane” DIEP flap is one we routinely consider in our algorithm, as it allows for full preservation of functional abdominal musculature, and offers enhanced flap perfusion by incorporating both the deep and superficial (dominant) vascular systems. This results in lower fat necrosis rates, particularly in the setting of post-reconstruction radiation.
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Yoshimatsu, Hidehiko, Ryo Karakawa, Yuma Fuse, Akitatsu Hayashi, and Tomoyuki Yano. "Superficial Circumflex Iliac Artery Perforator Flap Elevation Using Preoperative High-Resolution Ultrasonography for Vessel Mapping and Flap Design." Journal of Reconstructive Microsurgery 38, no. 03 (2021): 217–20. http://dx.doi.org/10.1055/s-0041-1736317.
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Abstract Background The superficial circumflex iliac artery (SCIA) perforator (SCIP) flap has gained acceptance among reconstructive microsurgeons, the minimal donor site morbidity being its greatest advantage. The purpose of this article is to introduce the use of preoperative ultrasonography to facilitate elevation and to avoid postoperative complications of the SCIP flap. Methods Preoperative mapping of the SCIA and the superficial circumflex iliac vein (SCIV) using a high-resolution ultrasound system were performed in patients undergoing reconstruction using a free SCIP flap. The skin paddle was designed placing the SCIA and the SCIV in the middle of the flap. Results Preoperatively marked SCIA and SCIV were found intraoperatively in all cases. The skin paddle design for sufficient arterial inflow and venous drainage resulted in no postoperative flap complications. Conclusion The use of a preoperative high-resolution ultrasound system significantly facilitates elevation of the SCIP flap, notably via the following 2 points: 1) pedicle can always be found under the markings made with preoperative ultrasonography, 2) satisfactory perfusion of the flap can be guaranteed via a safe flap design that includes preoperatively marked vessels within the skin paddle.
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Kumari, Swati. "A rare case of ovarian torsion in a pregnant patient." International Journal of Reproduction, Contraception, Obstetrics and Gynecology 11, no. 1 (2021): 255. http://dx.doi.org/10.18203/2320-1770.ijrcog20215114.
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Torsion of the ovary is the total or partial rotation of the adnexa around its vascular axis or pedicle. It is an uncommon cause of acute abdominal pain in females, and it is a gynecologic emergency. The majority of the cases present in the pregnant (22.7%) than in non-pregnant (6.1%) women. Diagnostic delay can result in loss of the ovary. This twisting initially obstructs venous flow, which causes engorgement and edema. The engorgement can progress until arterial flow is also compromised, leading to ischemia and infarction. The increased use of ovarian stimulation and assisted reproductive technology has led to an increase in the risk of adnexal torsion, particularly in pregnant women or women with ovarian hyperstimulation syndrome (OHSS). The differential diagnosis of adnexal torsion is particularly difficult in combination with OHSS or pregnancy, as abdominal pain, nausea and vomiting can be presenting symptoms of hyperstimulation or pregnancy as well. Here, we report a case of ovarian torsion occurring in pregnancy in which diagnostic delay occurred due to confusion with OHSS leading to oophorectomy. Fertility conservation may have been possible in case of earlier diagnosis and prompt treatment.
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Andarabi, Yasir, Farideh Nejat, and Mostafa El-Khashab. "Progressive skin necrosis of a huge occipital encephalocele." Indian Journal of Plastic Surgery 41, no. 01 (2008): 82–84. http://dx.doi.org/10.1055/s-0039-1699236.
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ABSTRACT Objects: Progressive skin necrosis of giant occipital encephalocoele is an extremely rare complication found in neonates. infection and ulceration of the necrosed skin may lead to meningitis or sepsis. we present here a neonate with giant occipital encephalocoele showing progressive necrosis during the first day of his life. Methods: a newborn baby was found to have a huge mass in the occipital region, which was covered by normal pink-purplish skin. during the last hours of the first day of his life, the sac started becoming ulcerated accompanied with a rapid color change in the skin, gradually turning darker and then black. the neonate was taken up for urgent excision and repair of the encephalocele. two years after the operation, he appears to be well-developed without any neurological problems.Conclusion: necrosis may have resulted from arterial or venous compromise caused by torsion of the pedicle during delivery or after birth. the high pressure inside the sac associated with the thin skin of the encephalocoele may be another predisposing factor. in view of the risk of ulceration and subsequent infection, urgent surgery of the necrotizing encephalocele is suggested.
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Verbat, Miroslava, Gauthier Zinner, Edward T. C. Dong, and Carlo M. Oranges. "The Impact of Hormonal Therapy on Autologous Microvascular Breast Reconstruction: A Systematic Review and Meta-analysis." Plastic and Reconstructive Surgery - Global Open 13, no. 6 (2025): e6868. https://doi.org/10.1097/gox.0000000000006868.
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Background: Hormonal therapy (HT) is pivotal in managing hormone receptor–positive breast cancer. However, in autologous microvascular breast reconstructions (AMBRs), HT raises concerns, particularly regarding venous thromboembolic (VTE) risk and its potential impact on flap viability. This systematic review and meta-analysis aimed to evaluate the impact of HT on complications of AMBR. Methods: We performed a systematic review and meta-analysis of all comparative studies reporting postoperative complications of AMBR in patients receiving HT in comparison with a control group. All types of free flaps were included. Complications were categorized and compared. Odds ratios and 95% confidence intervals were calculated using a random-effects model. Results: Eight studies, encompassing 4776 flaps performed on 3796 patients undergoing AMBR with or without HT, were included. Patients undergoing HT were treated with either selective estrogen receptor modulators (SERMs) or aromatase inhibitors. Five studies compared both treatments to a control group, whereas 3 studies focused on tamoxifen. Only studies with retrospective design could be included. There was no statistically significant difference between the 2 groups in terms of overall flap complication rates, partial and total flap loss, flap fat necrosis, flap pedicle arterial and/or venous thrombosis, or systemic VTE. Subgroup analysis revealed a significantly higher risk of systemic VTE in the SERMs group compared with controls, while other complications were not significant. Conclusions: Our results show that HT does not increase the risk of flap complications in the context of AMBR, whereas SERMs increase the risk of systemic VTE. Further research with prospective studies is warranted to confirm these findings.
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Nezic, Dusko, Aleksandar Knezevic, Milan Cirkovic, Miomir Jovic, Ljupco Mangovski, and Predrag Milojevic. "In situ pedicle graft and coronary-coronary bypass grafting using internal thoracic artery in management of multiple lesions of the left anterior descending coronary artery." Medical review 57, no. 11-12 (2004): 601–4. http://dx.doi.org/10.2298/mpns0412601n.
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Introduction Nowadays, coronary-coronary bypass grafting (CCBG) has been applied in patients with heavily calcified ascending aorta or due to lack of graft material. Case report We describe a case in which the patient's large left anterior descending (LAD) coronary artery, running well over the cardiac apex, presented with proximal and distal stenosis. Although the pedicled left internal thoracic artery (ITA) graft is sometimes too short for sequential bypass in cases of distal stenosis of the LAD coronary artery, we used a free, short segment of the pedicled left ITA for coronary-coronary bypass grafting. The in situ remnant of the left pedicled ITA was used to bypass the proximal LAD stenosis. The patient's postoperative course was uneventful. Predischarge angiogram (on the 9th postoperative day) showed an in situ left ITA graft as well as a free coronary-coronary ITA graft. The patient had a regular follow-up after 3 months, and was classified as New York Heart Association (NYHA) class I. Discussion Primarily used in aorto-coronary bypass surgery (termino-terminal interposition of the saphenous vein between two parts of a resected coronary artery), CCBG was revised latter on, and from hemodynamic point of view the physiologic restoration of coronary blood flow has been confirmed. CCBG might be an attractive approach for bypassing distal lesions of large coronary arteries (combined with arterial or venous grafting of targeted arteries, if proximal stenoses are also present). The proximal remnant of ITA can be used as an in situ or free graft.
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Khurram, Mohammed Fahud, and Somnath Karad. "Versatility of Proximal Sural Island Sensate Fasciocutaneous Flap in Reconstruction of Soft Tissue Defects of Knee and Proximal Leg." Journal of Wound Management and Research 20, no. 2 (2024): 137–44. http://dx.doi.org/10.22467/jwmr.2023.02775.
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Background: The proximal sural island sensate (PSIS) fasciocutaneous flap presents an ideal alternative in reconstruction of defects of the knee and proximal leg. It provides a thin sensate flap with good aesthetic outcomes and reduced donor site morbidity. However, only limited reports exist in the literature about this flap.Methods: This is a retrospective study done between December 2018 and December 2021 including 30 patients, among which seven cases had defects located on the knee and 23 cases in the proximal part of the leg. Mean age of the study population was 41 years. The maximum flap size was 8×12 cm, while the maximum pedicle length was 15 cm.Results: All 30 flaps survived well with only minimal complications occurring in a few patients such as epidermal loss and distal tip necrosis. No arterial or venous crisis occurred postoperatively in any case. Donor sites were managed with one-stage primary closure or split-thickness skin grafts. Functional deficits were not detected in any of the cases.Conclusion: We found the PSIS fasciocutaneous flap to be a simple and reliable technique to perform. The flap offers extensive coverage, reaching from the knee to the proximal leg, and provides thin, pliable, and sensate skin, resulting in excellent aesthetic and functional outcomes.
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Sá, Jairo Zacchê de, José Lamartine de Andrade Aguiar, Adriana Ferreira Cruz, Alexandre Ricardo Pereira Schuler, José Ricardo Alves de Lima, and Olga Martins Marques. "The effects of local nitroglycerin on the surgical delay procedure in prefabricated flaps by vascular implant in rats." Acta Cirurgica Brasileira 27, no. 12 (2012): 905–11. http://dx.doi.org/10.1590/s0102-86502012001200013.
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PURPOSE: To evaluate the effect of local nitroglycerin on the viable area of a prefabricated flap for vascular implant in rats, and to investigate the surgical delay procedure. METHODS: A femoral pedicle was implanted under the skin of the abdominal wall in forty Wistar rats. The animals were divided into four groups of ten: group 1 - without surgical delay procedure and local nitroglycerin; group 2 - with surgical delay procedure, but without local nitroglycerin; group 3 - without surgical delay procedure, but with local nitroglycerin; and group 4 - with simultaneous surgical delay procedure and local nitroglycerin. The percentages of the viable areas, in relation to the total flap, were calculated using AutoCAD R 14. RESULTS: The mean percentage value of the viable area was 8.9% in the group 1. 49.4% in the group 2; 8.4% in the group 3 and 1.1% in the group 4. There was significant difference between groups 1 and 2 (p=0.005), 1 and 4 (p=0.024), 2 and 3 (p=0.003), 2 and 4 (p=0.001). These results support the hypothesis that the closure of the arterial venous channels is responsible for the phenomenon of surgical delay procedure. CONCLUSION: Local nitroglycerin did not cause an increase in the prefabricated viable flap area by vascular implantation and decreased the viable flap area that underwent delay procedures.
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Kapoor, Akshay, Malay Karmakar, Collin Roy, and Kaushal Priya Anand. "Assessment of perfusion of free flaps used in head and neck reconstruction using pulsatility index." Indian Journal of Plastic Surgery 50, no. 02 (2017): 173–79. http://dx.doi.org/10.4103/ijps.ijps_23_17.
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ABSTRACTObjective: To detect venous or arterial obstruction in the pedicle of a free flap we can monitor resistance in the flap bed which is reflected in Pulsatility Index (PI) Therefore if we detect change in the values of the PI in these flaps then we can detect complications in flap due to vascular insufficiency early. Materials and Methods: Seven patients of Free Fibular Flap Reconstruction and ten patients of Free Radial Forearm Flap reconstruction were evaluated over a period of 18 months. In the pre op we recorded PI of Radial and Peroneal artery using colour doppler study. In the Post Operative Period 2 readings of PI at the anastomotic site were taken on Day 1 and Day 7. Results: Both Free Radial Forearm and Free Fibula flaps which were healthy (n = 15) showed a significant decrease in PI values on first Post Op day as compared to Pre Op. Also there was a significant fall in PI on Post Op Day 7 as compared to post op Day 1 (P < 0.05) in these flaps. The flaps developing complications (n = 2) had significantly higher Day 1 Post op PI readings as compared to healthy flaps (P < 0.05). Conclusion: PI is an objective index which can indicate changes in perfusion of free flaps used in Head and Neck reconstruction based on which we can predict if a flap is susceptible to circulatory compromise.
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Yoshioka, Nobutaka, and Albert L. Rhoton. "Vascular Anatomy of the Anteriorly Based Pericranial Flap." Operative Neurosurgery 57, suppl_1 (2005): 11–16. http://dx.doi.org/10.1227/01.neu.0000163477.85087.b1.
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Abstract OBJECTIVE: The purpose of this study was to examine the vascular supply of the anteriorly based frontal pericranial flap to determine whether separating the pericranium from the galea above the orbital rim would devascularize the pericranial flap. METHODS: The arteries supplying and the veins draining the frontal pericranial flap were examined in 17 adult cadavers using ×3 to ×30 magnification. The arteries were examined on 25 sides and the veins on 16 sides. RESULTS: The main trunk and superficial branches of the supraorbital and supratrochlear arteries, which course in the galea-frontalis muscle layer, give rise to the deep branches that supply the pericranium. These pericranial branches may arise in the orbit or at the level of or above the orbital rim. Pericranial arteries that arose above the level of the orbital rim and would be divided in separating the galea and pericranium were found in 28% of the sides examined. Pericranial veins that coursed above the orbital rim and would be divided in separating the galea-frontalis muscle layer from the pericranial layer were found in 43.8% of the sides examined. CONCLUSION: In preparing a pericranial flap based anteriorly on the supraorbital rim, the separation of the galea-frontalis muscle layer from the pericranium layer should not extend into the 10 mm above the supraorbital rim if the arterial and venous pedicle of the pericranial flap is to be preserved.
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Moens, Noel M. M., and J. David Fowler. "The Microvascular Carpal Foot Pad Flap: Results in Three Clinical Cases." Veterinary and Comparative Orthopaedics and Traumatology 10, no. 04 (1997): 187–91. http://dx.doi.org/10.1055/s-0038-1632593.
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SummaryFour microvascular carpal foot pad transfers were performed on three dogs for reconstruction of weight bearing surfaces. All of the dogs had suffered severe trauma to the major weight bearing foot pads of at least one foot due to: burn injury (one dog), ischaemic injury (one dog) or sharp trauma (one dog). The vascular anatomy of the carpal foot pad flap was consistent in all of the dogs. The arterial pedicle arose from the caudal interosseous artery and the venous effluent drained via the cephalic vein. All of the flaps survived transfer. Post-operative care included heavily padded bandages and daily visual assessment of flap viability. All of the flaps developed partial wound dehiscence along their distal borders, presumably due to incisional stresses from weight bearing. The flaps were surgically repositioned as necessary in order to maintain a central weight bearing position. Ultimately, all of the flaps healed and hypertrophied to accomodate weight bearing stresses. In all dogs functional results were good.Foot pads are highly specialized to withstand the hostile environments into which they are placed. Reconstruction of weight bearing surface following loss of foot pads, therefore, is difficult. Microvascular free transfer of foot pads allows the reconstruction of such deficits with tissue that is, anatomically, most appropriately suited to adopt the function of weight bearing. Microvascular free transfer of the carpal foot pad flap for foot reconstruction is demonstrated in three clinical cases.
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Maier, Mark A., Patrick A. Palines, Richard F. Guidry, and Mark W. Stalder. "Use of Flow-through Free Flaps in Head and Neck Reconstruction." Plastic and Reconstructive Surgery - Global Open 12, no. 3 (2024): e5588. http://dx.doi.org/10.1097/gox.0000000000005588.
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Background: Reconstructive obstacles in composite head and neck defects are compounded in reoperated, traumatized, irradiated, and vessel-depleted surgical fields. In cases that require multiple free flaps, recipient vessel accessibility and inset logistics become challenging. Strategic flow-through flap configurations mitigate these issues by supplying arterial inflow and venous outflow to a second flap in a contiguous fashion. This approach (1) permits the use of a singular native recipient vessel, (2) increases the reach of the vascular pedicle, avoiding the need for arteriovenous grafting, and (3) allows for a greater three-dimensional flexibility in configuring soft tissue and bony flap inset. Methods: To demonstrate this technique, we conducted a retrospective review of all head and neck reconstruction patients presenting to us from March 2019 to April 2021. Results: We present seven oncological and two traumatic patients (N = 9) who received flow-through free flaps for head and neck reconstruction. The most common flap used as the flow-through flap was the anterolateral thigh flap (N = 7), followed by the fibula flap (N = 2). Mean follow-up time was 507 days. No flap failures occurred. Conclusion: In head and neck reconstruction, the use of the flow-through principle enables uninterrupted vascular flow for two distinct free flaps in single-stage reconstruction for patients with vessel-depleted, irradiated, and/or reoperated fields. We demonstrate that flow-through flaps in the head and neck may be used successfully for a variety of cases and flaps.
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Stringa, Pablo, Nidia Arreola, Ane Moreno, Carlota Largo, Martín Rumbo, and Francisco Hernandez. "Modified Multivisceral Transplantation with Native Spleen Removal in Rats." European Journal of Pediatric Surgery 29, no. 03 (2018): 253–59. http://dx.doi.org/10.1055/s-0038-1632375.
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Background Modified multivisceral transplantation (MMVTx) refers to the use of a graft that includes all abdominal organs except the liver. The use of this type of transplant in children and adults expanded over the last years with good results. However, long-term survival in experimental models has not been reported. Our aim is to describe in detail some technical modifications of MMVTx to obtain long-term survival. Materials and Methods Syngeneic (Lewis–Lewis) heterotopic MMVTx was performed in 16 male rats (180–250 g). All procedures were performed under isoflurane anesthesia. The graft consisted of stomach, duodenopancreatic axis, spleen, and small bowel. The vascular pedicle consisted of a conduit of aorta, including the celiac trunk and the superior mesenteric artery (SMA), and the portal vein (PV). The engraftment was performed by end-to-side anastomosis to the infra-renal cava vein and aorta. After reperfusion, the graft was accommodated in the right side of the abdomen, and a terminal ileostomy performed. The native spleen was removed. Results Donor and recipient time was 39 ± 4.4 minutes and 69 ± 7 minutes, respectively; venous and arterial anastomosis time was 14 ± 1 minutes and 12.3 ± 1 minutes, respectively. Total ischemia time was 77.2 ± 7.9 minutes. Survival was 75% (12/16), six were sacrificed after 2 hours, and six were kept alive for long-term evaluation (more than 1 week). Conclusion Long-term survival is reported after heterotopic MMVTx in rats. The heterotopic MMVTx with native spleen removal would potentially improve the existent models for transplant research. The usefulness of this model warrants further confirmation in allogeneic experiments.
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Salman, Malik, Syed Sardar Rahim, Ahmad Kamran Khan, et al. "Comparison Between Saphenous Vein Graft and Radial Artery Graft in Coronary Artery Bypass Grafting." Pakistan Journal of Medical and Health Sciences 15, no. 12 (2021): 3378–80. http://dx.doi.org/10.53350/pjmhs2115123378.
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Background: To bypass the obstruction in native coronary arteries both arterial and venous grafts are used. Inspite of having radial artery graft as a favored second conduit for bypass, venous grafts are more frequently used. Objective: To compare the CT angiography patency findings of radial artery graft vs. saphenous vein graft 3 months postoperatively. Study Design: Randomized controlled trial. Settings: The study was conductedat the Department of Cardiac Surgery, Mayo Hospital, Lahore. Data Collection: All patients fulfilling theinclusioncriteria were recruited. A written informed consentwastaken. The non-dominant arm was used almostexclusively forharvesting the radial artery in those patients who have positive modified Allen`s test as a pedicle by atraumatic "no-touch" technique. After heparanization, it was immersed in diluted solution (Inj. verapamil hydrochloride 5mg + Inj. nitroglycerin 2.5mg + Inj. heparin 500 IU + Inj. ringer lactate 300 ml with Inj. 8.4% NaHCO3 0.9 m1). All the patients in the study received LIMA to LAD and were done on pump. After that the patients were dividedinto2 groups namely Group I and Group II by computer generated method. In Group I, the patient received the radial artery as a second graft to a coronary having more than 90% stenosis. The third or fourth graft if required is saphenous vein graft. The group II had SVG as second, third or fourth grafts, one of the venous grafts were to a coronary having more than 90% stenosis. Results: Average age of all (n=62) patients was 38.82±9.93 years. Average age in Group-I & II patients was 39.09±9.49 & 38.54±10.50 years respectively. Among patients 47% were male and 53% were female patients. In Group-I, 12 (38.7%) of the patients were male, and 19 (67.3%) were female, whereas in Group-II, 17 (54.8%) of the patients were male, and 14 (45.8%) were female. In Group-I 1(3.2%) patient and in Group-II 3(9.7%) patients died (p=0.301). Insignificant difference was seen for cardiac arrhythmias i.e. Group-I:16.1% vs. Group-II: 19.4%, p=0.740. Myocardial infarction in Group-A 5(16.1%) patients and in Group-B 7(22.6%) (p=0.520). In Group-A, 30(96.8%) patients and in Group-B, 28(90.3%) patients showed patency of artery after coronary artery bypass grafting(P>0.05). Conclusion: We discovered no significant difference in the patency of both radial artery and saphenous vein grafts on 3 months postoperative CT angiography and clinical outcomes in terms of perioperative mortality, MI, and cardiac arrhythmias in patients who underwent CABG in this study. Keywords: radial artery graft, saphenous vein graft, coronary artery bypass grafting, Myocardial Infarction, Mortality, Cardiac arrhythmias