A single Angiofil-latex injection for both radiological and anatomical assessment of arterial territories in the limbs.

INTRODUCTION: Postmortem evaluation of the human vascular system has a long history, with advancements ranging from dissections to modern imaging techniques like computed tomography (CT scan). This study designs a novel combination of Angiofil, a liquid radiopaque polymer, and latex, a flexible cast material, for cadaveric vascular analysis. MATERIAL & METHODS: The aim was to synergize the advantages of both components, providing accurate radiological images and optimal dissection conditions. Three arterial territories (lateral circumflex femoral artery, profunda brachii artery, and radial artery) were injected and assessed through CT scans and dissections. RESULTS: The Angiofil-latex mixture allowed successful visualization of the vascular networks, offering a simple, reproducible, and non-toxic approach. Quantitative assessments of the three territories, including diameters and lengths, showed comparable results between CT scan and dissection. DISCUSSION: The technique precision and versatility make it an accessible and valuable tool for anatomical studies, potentially extending its application to MRI analyses. Overall, the Angiofil-latex combination presents a cost-effective solution for researchers, offering enhanced visibility and detailed anatomical insights for various applications, including anatomical variation studies.

Adjacent venous tumour thrombus in primary osteosarcoma of the pelvis and limbs.

Aims: Venous tumour thrombus (VTT) is a rare finding in osteosarcoma. Despite the high rate of VTT in osteosarcoma of the pelvis, there are very few descriptions of VTT associated with extrapelvic primary osteosarcoma. We therefore sought to describe the prevalence and presenting features of VTT in osteosarcoma of both the pelvis and the limbs. Methods: Records from a single institution were retrospectively reviewed for 308 patients with osteosarcoma of the pelvis or limb treated between January 2000 and December 2022. Primary lesions were located in an upper limb (n = 40), lower limb (n = 198), or pelvis (n = 70). Preoperative imaging and operative reports were reviewed to identify patients with thrombi in proximity to their primary lesion. Imaging and histopathology were used to determine presence of tumour within the thrombus. Results: Tumours abutted the blood vessels in 131 patients (43%) and encased the vessels in 30 (10%). Any form of venous thrombus was identified in 31 patients (10%). Overall, 21 of these thrombi were determined to be involved with the tumour based on imaging (n = 9) or histopathology (n = 12). The rate of VTT was 25% for pelvic osteosarcoma and 1.7% for limb osteosarcoma. The most common imaging features associated with histopathologically proven VTT were enhancement with contrast (n = 12; 100%), venous enlargement (n = 10; 83%), vessel encasement (n = 8; 66%), and visible intraluminal osteoid matrix (n = 6; 50%). Disease-specific survival (DSS) for patients with VTT was 95% at 12 months (95% CI 0.87 to 1.00), 50% at three years (95% CI 0.31 to 0.80), and 31% at five years (95% CI 0.14 to 0.71). VTT was associated with worse DSS (hazard ratio 2.3 (95% CI 1.11 to 4.84). Conclusion: VTT is rare with osteosarcoma and occurs more commonly in the pelvis than the limbs. Imaging features suggestive of VTT include enhancement with contrast, venous dilation, and vessel encasement. VTT portends a worse prognosis for patients with osteosarcoma, with a similar survivability to metastatic disease.

Therapeutic limb hypothermia for the treatment of traumatic acute limb ischemia.

Acute limb ischaemia (ALI) is an emergent clinical condition that strains pre-hospital resources and impacts healthcare costs and patient quality of life. Hypothermia has long been used in clinical and research settings to mitigate ischaemic damage in tissues, but prompt reperfusion is needed to prevent loss of limb or function from ALI. To address the unmet need for pre-hospital intervention of threatened limbs awaiting definitive specialty care, we have focused on controlled application of hypothermia. Over years of animal experiments, phantom limb creation, and materials selection, we conceptualised and created a portable limb-cooling device that can be used alone or combined with a traditional tourniquet or resuscitative endovascular balloon occlusion of the aorta. Here, we describe our process of building and testing the device, from computer simulation through animal-limb metabolic studies, to prototype testing.

Who needs a tourniquet? And who does not? Lessons learned from a review of tourniquet use in the Russo-Ukrainian war.

BACKGROUND: Extremity tourniquets have proven to be lifesaving in both civilian and military settings and should continue to be used by first responders for trauma patients with life-threatening extremity bleeding. This is especially true in combat scenarios in which both the casualty and the first responder may be confronted by the imminent threat of death from hostile fire as the extremity hemorrhage is being treated. Not every extremity wound, however, needs a tourniquet. One of the most important aspects of controlling life-threatening extremity bleeding with tourniquets is to recognize what magnitude of bleeding requires this intervention and what magnitude of bleeding does not. Multiple studies, both military and civilian, have shown that tourniquets are often applied when they are not medically indicated. Overuse of extremity tourniquets has not caused excess morbidity in either the recent conflicts in Iraq and Afghanistan or in the US urban civilian setting. In the presence of prolonged evacuation, however, applying a tourniquet when it is not medically indicated changes tourniquet application from being a lifesaving intervention to one that may cause an avoidable amputation and the development of an array of metabolic derangements and acute kidney injury collectively called prolonged tourniquet application syndrome. METHODS: The recent literature was reviewed for papers that documented the complications of tourniquet use resulting from the prolonged casualty evacuation times being seen in the current Russo-Ukrainian war. The literature was also reviewed for the incidence of tourniquet application that was found to not be medically indicated, in both the US civilian setting and from Ukraine. Finally, an in-person meeting of the US/Ukraine Tourniquet Working Group was held in Warsaw, Poland, in December of 2023. RESULTS: Unnecessary loss of extremities and life-threatening episodes of prolonged tourniquet application syndrome are currently occurring in Ukrainian combat forces because of nonindicated tourniquet use combined with the prolonged evacuation time seen in the Russo-Ukrainian war. Specific numbers of the complications experienced as a result of tourniquet use by Ukrainian forces in the current conflict are treated as classified information and are not available, but multiple sources from the Ukrainian military medical personnel and from the US advisors providing medical assistance to Ukraine have all agreed that the problem is substantial. CONCLUSION: Unnecessary tourniquet morbidity might also occur in US forces in a variety of potential future combat scenarios in which evacuation to surgical care is delayed. Prehospital trauma training programs, including but not limited to tactical combat casualty care, place insufficient emphasis on the need to avoid leaving tourniquets in place when they are not medically indicated. This aspect of training should receive emphasis in future Tactical Combat Casualty Care (TCCC) and civilian first responder curriculum development. An interim ad hoc training solution on this topic is available at the websites noted in this articles. Additional training modalities may follow in the near future. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

A novel translational model of atherosclerosis, the ex vivo pump-perfused amputated human limb model.

The preclinical study of atherosclerosis has traditionally centred around the use of small animal models, translating to large animal models, prior to first-in-man studies. We propose to disrupt this paradigm by designing an ex vivo pump perfused human limb model. The novel model consists of taking a freshly amputated limb and incorporating it into an ex situ pump-perfused bypass system (akin to extracorporeal membrane oxygenation), circulating warmed, oxygenated blood. The circuit incorporates an introducer sheath and guiding catheter for intravascular imaging and X-ray angiography. Regular monitoring is performed using blood gas analysis, aiming for physiological parameters. The model maintains oxygen saturations > 99% for the length of perfusion (up to 6-h). Clinical grade X-ray angiography, intravascular ultrasound and optical coherence tomography have been successfully performed. Indocyanine green, a near-infrared fluorescent dye that localises to atherosclerotic plaque, has been injected into the system and left to circulate for 90-min. Fluorescence reflectance imaging of the dissected arterial bed confirmed uptake in areas of calcific atherosclerotic plaque on intravascular imaging. This is the first demonstration of an ex vivo pump-perfused "living" limb experimental model of atherosclerosis, which shows promise for future studies in translational interventional imaging and molecular targeting.

Molecular Insight into Acute Limb Ischemia.

Acute limb ischemia (ALI) is defined as a sudden reduction in blood flow to a limb, resulting in cessation of blood flow and, therefore, cessation of the delivery of nutrients and oxygen to the tissues of the lower limb. Despite optimal treatment to restore blood flow to ischemic tissues, some patients may suffer from ischemia/reperfusion (I/R) syndrome, the most severe complication after a revascularization procedure used to restore blood flow. There are multiple molecular and cellular factors that are involved in each phase of ALI. This review focuses firstly on molecular and cellular factors of arterial thrombosis, highlighting the role of atherosclerotic plaques, smooth muscle cells (SMCs), and cytokine which may alter key components of the extracellular matrix (ECM). Then, molecular and cellular factors of arterial embolism will be discussed, highlighting the importance of thrombi composition. Molecular and cellular factors of ischemia/reperfusion syndrome are analyzed in depth, highlighting several important mechanisms related to tissue damage, such as inflammation, apoptosis, autophagy, necrosis, and necroptosis. Furthermore, local and general complications of ALI are discussed in the context of molecular alterations. Ultimately, the role of novel biomarkers and targeted therapies is discussed.

[Surgical treatment of traumatic arteriovenous fistulas of extremities]. / Osobennosti khirurgicheskogo lecheniya travmaticheskikh arteriovenoznykh fistul konechnostei.

The number of victims with damage to the great vessels has increased in recent years due to escalation of armed conflicts. Vascular damages comprise 3% of traumatic injuries in peacetime, and their incidence increases to 15% during hostilities. False aneurysms and traumatic arteriovenous fistulas follow vascular injury in 48.9-68.7% of cases. We present open surgical treatment of traumatic arteriovenous fistulas. The issues of diagnosis, surgical tactics, algorithm of intervention and options for successful treatment are described.

Vascular complications in extremities of physically restrained intensive care unit patients: A prospective, observational study.

BACKGROUND: Physical restraint is used to prevent agitation, to continue treatments and to ensure safety in intensive care patients. Physical restraint has negative effects on physical and psychological health, and physical restraint should not be used unless necessary. AIMS: The purpose of this study was to evaluate the development of vascular complications in extremities of physically restrained patients hospitalized in the intensive care unit (ICU) and the associated factors. STUDY DESIGN: A prospective, observational study. The study was conducted between September 1, 2022, and March 31, 2023 in eight ICUs of a hospital located in the inner regions of Türkiye. The development of vascular complications (discolouration, distemperature, variations in capillary refill time, fluctuations in peripheral pulse, skin ulceration and oedema in the area of physical restraint) rate in patients hospitalized in the ICUs who were physically restrained. Independent sample t test, Mann-Whitney U test and Pearson-χ2 test were used to analyse the data. RESULTS: During the study, 2409 patients were admitted to ICUs. Physical restraint was applied to 209 of these patients. Of the 209 patients, 112 patients who met the inclusion criteria were included in the study. The physical restraint site of the patients was evaluated an average of 230.12 times and physical restraint was terminated in 9.8% of the patients (n = 112) because of vascular complications that developed in the physical restraint site. The rate of vascular complications at the site of physical restraint was higher in patients with endotracheal tubes (p < .05), lower GCS scores (p < .05) and higher INR values (p < .05). Patients with skin ulceration at the restraint site received more massages and cream applications (%95CL = 1. 1.692-34.734, OR = 7.667, p = .032). It was determined that more massage was applied to patients with changes in skin temperature at the restraint site (%95Cl = 1.062-11.599, OR = 3.510, p = .032). CONCLUSIONS: Vascular complications may develop at the restraint site in patients hospitalized in the ICU. This may be more common in ICU patients with endotracheal tube, lower GCS score and higher INR values. RELEVANCE TO CLINICAL PRACTICE: Nurses should closely monitor ICUs patients with endotracheal tube, lower GCS score and higher INR values, and implement care interventions to prevent the development of vascular complications.

Increased Mortality in Patients Transferred to a Level 1 Trauma Center with Blunt and Penetrating Extremity Vascular Injuries.

BACKGROUND: Trauma care depends on a complex transfer system to ensure timely and adequate management at major trauma centers. Patient outcomes depend on the reliability of triage in local or community hospitals and access to tertiary or quaternary trauma institutions. Patients with polytrauma, extremity trauma, or vascular injuries require multidisciplinary management at trauma hospitals. Our study investigated outcomes in this population at a level one trauma center in San Bernardino County, the largest geographic county in the contiguous United States. METHODS: We conducted a retrospective review of all patients with extremity trauma who presented to a single level 1 trauma center over 10 years. The cohort was divided into following two groups: 1. transferred from another medical center for a higher level of care or 2. those who directly presented. Overall, 19,417 patients were identified, with 15,317 patients presenting directly and 3,830 patients transferred from an outside hospital. Extremity of vascular injuries was observed in 268 patients. Demographic data were ascertained, including the injury severity score, mechanism of injury, response level, arrival method, tertiary center emergency department disposition, and presence of vascular injury in the upper or lower extremities. Univariate and multivariate analyses were performed to assess patient mortality. RESULTS: A total of 268 patients with vascular injuries were analyzed, including 207 nontransferred and 61 transferred patients. In the univariate analysis, injury severity score means were compared at 11.4 in nontransferred patients versus 8.4 in transferred (P < 0.001), 50% of blunt injury in the nontransferred group, and 28% in the transferred group (P < 0.001); in-hospital mortality was 4% in nontransferred patients versus 28% in the transferred group (P < 0.001). Multivariate logistic regression demonstrated that mortality is 8 times more likely if a patient with vascular extremity injuries is transferred from an outside hospital. A 10% mortality rate was observed in patients without blood transfusion within 4 hr of arrival to the trauma center and 3% mortality in transferred patients transfused blood. CONCLUSIONS: Extremity trauma with vascular injury can be lethal if managed appropriately. Patients transferred to our level 1 trauma center had a substantial increase in mortality compared with nontransferred patients. Furthermore, the transfer distance was associated with increased mortality. Further research is required to address this vulnerable patient population.

A fluctuating intensity of care: A qualitative study on the experiences of informal caregivers of patients with critical limb-threatening ischemia.

Informal caregivers play a significant role in providing care for older, often vulnerable, patients, and supporting them as they live with chronic diseases. Due to the rising prevalence of older vascular patients and their use of healthcare, the role of their informal caregivers will become more important. However, little is known about the experiences of informal caregivers of patients with critical limb-threatening ischemia and the impact of informal care on different aspects of these caregivers' lives. In addition, literature does not describe the burden this role brings with it, or lack thereof. Therefore a qualitative study using a phenomenological approach, specifically interpretive phenomenological analysis, was used to gain insight into the experiences of the primary informal caregivers of patients with chronic limb-threatening ischemia. Data were collected via semi-structured interviews and focus groups discussions. Fifteen primary informal caregivers of patients with critical limb-threatening ischemia under the care of the vascular surgeon at a tertiary teaching hospital in the Netherlands were included. Data analysis yielded three themes: the perceived identity of this group of caregivers; the varying intensity of informal care; and the collaboration between informal carers, their care recipients and the professional care provider within the vascular surgery department. In contrast to carers of other chronic diseases, the shifting intensity of care that informal caregivers of critical limb-threatening ischemia patients experience seems to prevent long-term overload. Adapting to that fluctuating situation requires flexibility from healthcare providers within the vascular surgery department. In addition, professionals need to involve informal caregivers in the patient's decision-making process and recognize their role in that process.

Characteristics and Validation of Pediatric Extremity Vascular Trauma in Dedicated Pediatric and Adult Trauma Centers: A Scoping Review Protocol.

BACKGROUND: Pediatric extremity vascular injuries constitute a rare yet serious entity that can lead to serious complications especially if left untreated or become late diagnosed. In our scoping review, we sought to evaluate different characteristics and outcomes of pediatric and combined adult trauma centers (ATCs) in the management of pediatric extremity vascular injury. METHODS: We sought to analyze various characteristics and parameters that differentiate a dedicated pediatric and a combined pediatric ATC in terms of effectiveness and quality of care in the acute setting and to describe special features and characteristics of an acute vascular disease that constitute pediatric population unique from the aspect of diagnosis and management. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews guidelines to conduct the study. RESULTS: The search identified 8,815 records in title using MeSH terms from PubMed/MEDLINE database among which 12 studies reporting a total of 2,124 pediatric patients with vascular extremity injuries were included for analysis. Incidence of pediatric extremity vascular injury was 0.5%. Upper extremity injuries were the most frequent presenting in 63% of cases followed by lower extremity injuries in 37% of cases. Blunt injuries were marginally more common than penetrating injuries (58% vs. 42%). In-hospital mortality and morbidity ranged from 13.2% to 0.9% and 13% to 30%, respectively. Limb-salvage rates were high, ranging from 92% to 99%. Furthermore, there are no clearly defined clinical guidelines involving the mode of imaging and diagnosis, the surgical specialties involved and the competency of nursing or medical staff overall. CONCLUSIONS: Dedicated children trauma centers theoretically represent the optimal path for acute pediatric trauma admission, especially in complex trauma necessitating vascular reconstruction. However, in the current setting of rapidly increasing health costs and economic crisis worldwide, regional or resource-related factors make this option rather unavailable. In any case, it is imperative the clinicians have a high index of suspicion when confronting with these types of injuries because early diagnosis is highly related with reduced morbidity and superior outcomes.

Limb Ischemic Necrosis Secondary to Microvascular Thrombosis: A Brief Historical Review.

Ischemic limb injury can be broadly classified into arterial (absent pulses) and venous/microvascular (detectable pulses); the latter can be divided into two overlapping disorders-venous limb gangrene (VLG) and symmetrical peripheral gangrene (SPG). Both VLG and SPG feature predominant acral (distal) extremity ischemic necrosis, although in some instances, concomitant nonacral ischemia/skin necrosis occurs. Historically, for coagulopathic disorders with prominent nonacral ischemic necrosis, clinician-scientists implicated depletion of natural anticoagulants, especially involving the protein C (PC) system. This historical review traces the recognition of natural anticoagulant depletion as a key feature of nonacral ischemic syndromes, such as classic warfarin-induced skin necrosis, neonatal purpura fulminans (PF), and meningococcemia-associated PF. However, only after several decades was it recognized that natural anticoagulant depletion is also a key feature of predominantly acral ischemic microthrombosis syndromes-VLG and SPG-even when accompanying nonacral thrombosis is not present. These acquired acral limb ischemic syndromes typically involve the triad of (a) disseminated intravascular coagulation, (b) natural anticoagulant depletion, and (c) a localizing explanation for microthrombosis occurring in one or more limbs, either deep vein thrombosis (helping to explain VLG) or circulatory shock (helping to explain SPG). In most cases of VLG or SPG there are one or more events that exacerbate natural anticoagulant depletion, such as warfarin therapy (e.g., warfarin-associated VLG complicating heparin-induced thrombocytopenia or cancer hypercoagulability) or acute ischemic hepatitis ("shock liver") as a proximate factor predisposing to severe depletion of hepatically synthesized natural anticoagulants (PC, antithrombin) in the setting of circulatory shock.

Evolution of distal limb perfusion management in adult peripheral venoarterial extracorporeal membrane oxygenation with femoral artery cannulation.

Limb ischaemia is a clinically relevant complication of venoarterial extracorporeal membrane oxygenation (VA ECMO) with femoral artery cannulation. No selective distal perfusion or other advanced techniques were used in the past to maintain adequate distal limb perfusion. A more recent trend is the shift from the reactive or emergency management to the pro-active or prophylactic placement of a distal perfusion cannula to avoid or reduce limb ischaemia-related complications. Multiple alternative cannulation techniques to the distal perfusion cannula have been developed to maintain distal limb perfusion, including end-to-side grafting, external or endovascular femoro-femoral bypass, retrograde limb perfusion (e.g., via the posterior tibial, dorsalis pedis or anterior tibial artery), and, more recently, use of a bidirectional cannula. Venous congestion has also been recognized as a potential contributing factor to limb ischaemia development and specific techniques have been described with facilitated venous drainage or bilateral cannulation being the most recent, to reduce or avoid venous stasis as a contributor to impaired limb perfusion. Advances in monitoring techniques, such as near-infrared spectroscopy and duplex ultrasound analysis, have been applied to improve decision-making regarding both the monitoring and management of limb ischaemia. This narrative review describes the evolution of techniques used for distal limb perfusion during peripheral VA ECMO.

Effectiveness and safety of tourniquet utilization for civilian vascular extremity trauma in the pre-hospital settings: a systematic review and meta-analysis.

BACKGROUND: Tourniquets (TQ) have been increasingly adopted in pre-hospital settings recently. This study examined the effectiveness and safety of applying TQ in the pre-hospital settings for civilian patients with traumatic vascular injuries to the extremities. MATERIALS AND METHODS: We systematically searched the Ovid Embase, PubMed, and Cochrane Central Register of Controlled Trials databases from their inception to June 2023. We compared pre-hospital TQ (PH-TQ) use to no PH-TQ, defined as a TQ applied after hospital arrival or no TQ use at all, for civilian vascular extremity trauma patients. The primary outcome was overall mortality rate, and the secondary outcomes were blood product use and hospital stay. We analyzed TQ-related complications as safety outcomes. We tried to include randomized controlled trials (RCTs) and non-randomized studies (including non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies, and case-control studies), if available. Pooled odds ratios (ORs) were calculated and the certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. RESULTS: Seven studies involving 4,095 patients were included. In the primary outcome, pre-hospital TQ (PH-TQ) use significantly decrease mortality rate in patients with extremity trauma (odds ratio [OR], 0.48, 95% confidence interval [CI] 0.27-0.86, I2 = 47%). Moreover, the use of PH-TQ showed the decreasing trend of utilization of blood products, such as packed red blood cells (mean difference [MD]: -2.1 [unit], 95% CI: -5.0 to 0.8, I2 = 99%) or fresh frozen plasma (MD: -1.0 [unit], 95% CI: -4.0 to 2.0, I2 = 98%); however, both are not statistically significant. No significant differences were observed in the lengths of hospital and intensive care unit stays. For the safety outcomes, PH-TQ use did not significantly increase risk of amputation (OR: 0.85, 95% CI: 0.43 to 1.68, I2 = 60%) or compartment syndrome (OR: 0.94, 95% CI: 0.37 to 2.35, I2 = 0%). The certainty of the evidence was very low across all outcomes. CONCLUSION: The current data suggest that, in the pre-hospital settings, PH-TQ use for civilian patients with vascular traumatic injury of the extremities decreased mortality and tended to decrease blood transfusions. This did not increase the risk of amputation or compartment syndrome significantly.

Technical considerations for isolated limb perfusion: A consensus paper.

BACKGROUND: Isolated limb perfusion (ILP) is a well-established surgical procedure for the administration of high dose chemotherapy to a limb for the treatment of advanced extremity malignancy. Although the technique of ILP was first described over 60 years ago, ILP is utilised in relatively few specialist centres, co-located with tertiary or quaternary cancer centres. The combination of high dose cytotoxic chemotherapy and the cytokine tumour necrosis factor alpha (TNFα), mandates leakage monitoring to prevent potentially serious systemic toxicity. Since the procedure is performed at relatively few specialist centres, an ILP working group was formed with the aim of producing technical consensus guidelines for the procedure to streamline practice and to provide guidance for new centres commencing the technique. METHODS: Between October 2021 and October 2023 a series of face to face online and hybrid meetings were held in which a modified Delphi process was used to develop a unified consensus document. After each meeting the document was modified and recirculated and then rediscussed at subsequent meeting until a greater than 90% consensus was achieved in all recommendations. RESULTS: The completed consensus document comprised 23 topics in which greater than 90% consensus was achieved, with 83% of recommendations having 100% consensus across all members of the working group. The consensus recommendations covered all areas of the surgical procedure including pre-operative assessment, drug dosing and administration, perfusion parameters, hyperthermia, leakage monitoring and theatre logistics, practical surgical strategies and also post-operative care, response evaluation and staff training. CONCLUSION: We present the first joint expert-based consensus statement with respect to the technical aspects of ILP that can serve as a reference point for both existing and new centres in providing ILP.

Feasibility and efficacy of indocyanine green in monitoring systemic drug leakage during isolated limb perfusion for recurrent melanoma of extremity.

Melanoma is known for its high metastatic potential and aggressive growth. Recurrence is common post-surgery, sometimes leading to unresectable disease. Locally recurrent unresectable melanoma of extremity has been treated with high-dose anticancer chemotherapy via isolated limb perfusion (ILP) to improve local efficacy of drug and salvage limbs. Standard ILP monitoring uses radiolabeled dyes, requiring specialized personnel and involving radiation exposure. In this case, we used indocyanine green (ICG) to track systemic drug leakage during ILP. A 47-year-old gentleman with recurrent malignant melanoma of the left foot, operated twice earlier and treated with adjuvant pembrolizumab, presented with multiple in-transit metastases in the limb. ILP was planned, with 5 mg ICG administered in the perfusion solution along with high-dose melphalan. Stryker's SPI PHI handheld device was employed to visualize ICG during ILP. Absence of fluorescence beyond the involved extremity, such as fingers, ears, and the abdominal wall, indicated no systemic drug dispersion. For control, technetium radiocolloid dye was co-administered, monitored by a precordial gamma probe, confirming no systemic leakage, and validating effectiveness of ICG in leakage monitoring. ICG proves to be a safe, reliable, cost-effective, radiation-free approach for precise systemic drug leakage monitoring during ILP for recurrent melanoma of extremity.

Tourniquet Use in Extremity-Based Microsurgery.

BACKGROUND: The use of tourniquets and their role in extremity-based microsurgery has not been thoroughly investigated. The purpose of this study was to investigate tourniquet use and its associated outcomes and complications. The authors hypothesize that tourniquets enhance visualization, bloodless approaches to vessel harvest, flap elevation, and anastomosis without added complications. METHODS: A retrospective chart review was completed for patients who had undergone extremity-based microsurgery with the use of a tourniquet between January 2018 and February 2022 at two large academic institutions. Demographic characteristics, initial reasons for surgery, complications, and outcomes were recorded. Patients were separated into groups based on tourniquet use during three operative segments: (1) flap elevation, (2) vessel harvest, and (3) microvascular anastomosis. An internal comparison of complication rate was performed between cases for which a tourniquet was used for one operative segment to all cases in which it was not used for the same operative segment. Univariate and multivariate statistical analyses were performed to identify statistically significant results. RESULTS: A total of 99 patients (106 surgeries) were included in this study across sites. The mean age was 41.2 years and 67.7% of the patients were male. The most common reason for microsurgical reconstruction was trauma (50.5%). The need for an additional unplanned surgery was the most common surgical complication (16%). A total of 70, 61, and 32% of procedures used a tourniquet for flap elevation, vessel harvest, and for anastomosis, respectively. Statistical analyses identified no difference in complication rates for procedures for which a tourniquet was or was not used for interventions. CONCLUSION: Based on these results, the authors state that tourniquets can be utilized for extremity-based microsurgery to enable bloodless dissection without the concern of increased complication rates.

Remote Ischemic Conditioning for Acute Stroke: The RESIST Randomized Clinical Trial.

Importance: Despite some promising preclinical and clinical data, it remains uncertain whether remote ischemic conditioning (RIC) with transient cycles of limb ischemia and reperfusion is an effective treatment for acute stroke. Objective: To evaluate the effect of RIC when initiated in the prehospital setting and continued in the hospital on functional outcome in patients with acute stroke. Design, Setting, and Participants: This was a randomized clinical trial conducted at 4 stroke centers in Denmark that included 1500 patients with prehospital stroke symptoms for less than 4 hours (enrolled March 16, 2018, to November 11, 2022; final follow-up, February 3, 2023). Intervention: The intervention was delivered using an inflatable cuff on 1 upper extremity (RIC cuff pressure, ≤200 mm Hg [n = 749] and sham cuff pressure, 20 mm Hg [n = 751]). Each treatment application consisted of 5 cycles of 5 minutes of cuff inflation followed by 5 minutes of cuff deflation. Treatment was started in the ambulance and repeated at least once in the hospital and then twice daily for 7 days among a subset of participants. Main Outcomes and Measures: The primary end point was improvement in functional outcome measured as a shift across the modified Rankin Scale (mRS) score (range, 0 [no symptoms] to 6 [death]) at 90 days in the target population with a final diagnosis of ischemic or hemorrhagic stroke. Results: Among 1500 patients who were randomized (median age, 71 years; 591 women [41%]), 1433 (96%) completed the trial. Of these, 149 patients (10%) were diagnosed with transient ischemic attack and 382 (27%) with a stroke mimic. In the remaining 902 patients with a target diagnosis of stroke (737 [82%] with ischemic stroke and 165 [18%] with intracerebral hemorrhage), 436 underwent RIC and 466 sham treatment. The median mRS score at 90 days was 2 (IQR, 1-3) in the RIC group and 1 (IQR, 1-3) in the sham group. RIC treatment was not significantly associated with improved functional outcome at 90 days (odds ratio [OR], 0.95; 95% CI, 0.75 to 1.20, P = .67; absolute difference in median mRS score, -1; -1.7 to -0.25). In all randomized patients, there were no significant differences in the number of serious adverse events: 169 patients (23.7%) in the RIC group with 1 or more serious adverse events vs 175 patients (24.3%) in the sham group (OR, 0.97; 95% CI, 0.85 to 1.11; P = .68). Upper extremity pain during treatment and/or skin petechia occurred in 54 (7.2%) in the RIC group and 11 (1.5%) in the sham group. Conclusions and Relevance: RIC initiated in the prehospital setting and continued in the hospital did not significantly improve functional outcome at 90 days in patients with acute stroke. Trial Registration: ClinicalTrials.gov Identifier: NCT03481777.