The role of ultrasonography in the diagnosis of persistent sciatic artery.

AIM: To investigate the accuracy of ultrasonography in the diagnosis of persistent sciatic artery (PSA) compared to computed tomography angiography (CTA). MATERIALS AND METHODS: From May 2002 to Dec 2018, 61 consecutive patients seen at Shandong Medical Imaging Research Institute with a clinical suspicion of PSA were included. Ultrasonography was used to assess the abdominal and lower-limb arteries. The main sonographic criteria for a positive diagnosis were the visualisation of PSA, the enlarged internal iliac artery, and abnormality of common femoral artery and superficial femoral artery. These data were compared with CTA findings. Kappa statistics was applied to determine the level of agreement. The sensitivity, specificity, positive and negative predictive values, accuracy, and Youden index of ultrasonography as a diagnostic method were assessed. RESULTS: Ultrasonography findings were positive in 16 of 61 patients with a clinical suspicion of PSA. The diagnosis was confirmed by CTA in 17 patients. There was one false-positive result and two false-negative results at ultrasonography. The kappa value was 0.875. The sensitivity, specificity, positive and negative predictive values, accuracy, and Youden index of ultrasonography were 88.2%, 97.7%, 93.8%, 95.6%, 95.1% and 0.859, respectively. CONCLUSIONS: Ultrasonography could be a reliable, accurate, and non-invasive diagnostic imaging method in the diagnosis of patients with suspected PSA.

A rare disease with a rare presentation: hemi-atrophy caused by fibromuscular dysplasia in a 27 month old girl.

We discuss the case of a 27-month-old girl afflicted with fibromuscular dysplasia. She presented with hemiatrophy of left upper and lower limbs, nail dystrophy, ulcers on the tips of her toes, cold and painful limbs, foot drop, and hypertension. The initial appearance started at 2 months of age and other diagnoses such as complex regional pain syndrome, reflex sympathetic syndrome, vasculitis and coagulation disorders had been considered. Angiography revealed that all the arterial branches of the left lower and upper limbs, from brachial to ulnar and radial, and from iliac and femoral to tibialis arteries were affected. Sural nerve biopsy confirmed the diagnosis. In the follow-up visits until 2 years after the patient's discharge she did not develop any new problem and her blood pressure was controlled by enalapril and amlodipine.

Cost-effectiveness analysis of drug-coated therapies in the superficial femoral artery.

OBJECTIVE: Drug-coated balloons (DCBs) may increase durability of endovascular treatment of superficial femoral artery (SFA) disease while avoiding stent-related risks. The purpose of this study was to use meta-analytic data of DCB studies to compare the cost-effectiveness of potential SFA treatments: DCB, drug-eluting stent (DES), plain old balloon angioplasty (POBA), or bare-metal stent (BMS). METHODS: A search for randomized controlled trials comparing DCB with POBA for treatment of SFA disease was performed. Hazard ratios were extracted to account for the time-to-event primary outcome of target lesion revascularization. Odds ratios were calculated for the secondary outcomes of primary patency (PP) and major amputation. Incorporating pooled data from the meta-analysis, cost-effectiveness analysis, assuming a payer perspective, used a decision model to simulate patency at 1 year and 2 years for each index treatment modality: POBA, BMS, DCB, or DES. Costs were based on current Medicare outpatient reimbursement rates. RESULTS: Eight studies (1352 patients) met inclusion criteria for meta-analysis. DCB outperformed POBA with respect to target lesion revascularization over time (pooled hazard ratio, 0.41; P < .001). Risk of major amputation at 12 months was not significantly different between groups. There was significantly improved 1-year PP in the DCB group compared with POBA (pooled odds ratio, 3.30; P < .001). In the decision model, the highest PP at 1 year was seen in the DES index therapy strategy (79%), followed by DCB (74%), BMS (71%), and POBA (64%). With a baseline cost of $9259.39 per patent limb at 1 year in the POBA-first group, the incremental cost per patent limb for each other strategy compared with POBA was calculated: $14,136.10/additional patent limb for DCB, $38,549.80/limb for DES, and $59,748,85/limb for BMS. The primary BMS option is dominated by being more expensive and less effective than DCB. Compared directly with DCB, DES costs $87,377.20 per additional patent limb at 1 year. Based on the projected PP at 1 year in the decision model, the number needed to treat for DES compared with DCB is 20. At current reimbursement, the use of more than two DCBs per procedure would no longer be cost-effective compared with DES. At 2 years, DCB emerges as the most cost-effective index strategy with the lowest overall cost and highest patency rates over that time horizon. CONCLUSIONS: Current data and reimbursements support the use of DCB as a cost-effective strategy for endovascular intervention in the SFA; any additional effectiveness of DES comes at a high price. Use of more than one DCB per intervention significantly decreases cost-effectiveness.

A Surgeon's Guide to Obtaining Hemorrhage Control in Combat-Related Dismounted Lower Extremity Blast Injuries.

The application of lessons learned on the battlefield for timely surgical control of lower extremity hemorrhage secondary to blast injuries to the civilian practice for similar wounding patterns from industrial accidents or terrorist activities is imperative. Although simple cut-down procedures are commonly sufficient for the control of blood vessels for distal extremity traumatic amputations, high-thigh or disarticulation wounding patterns often require more complex surgical methods. The following details both the decision-making process and operative techniques for controlling hemorrhage from lower extremity blast injuries.

Perforating arteries of the thigh: An anatomical and radiological study.

INTRODUCTION: We aimed to advance the understanding of the anatomy of the perforating branches of the profunda femoris artery to facilitate the avoidance of iatrogenic injury in surgery around the thigh and ensure safe percutaneous embolisation. METHODS: Dissection was carried out on seven cadavers, examining the relationship of the point of origin of the perforating branches of profunda femoris, relative to lines connecting palpable bony landmarks (lines A and B). These were compared with 16 computed tomography angiograms (CTA). Left to right variation within subjects and variation between the dissection and imaged group was examined. The anatomy of the two groups was then compared with that described in anatomical textbooks. RESULTS: The side to side variation in number of perforators was not significant in the dissection (P = 0.20) nor the CT group (P = 0.70). Similarly, the point of origin of the perforating vessels along lines A and B did not demonstrate any significant difference except for the fourth perforator along line B (P = 0.03). There was no significant difference in points of origin along line B between the dissection and CT groups for the first four perforators on the left (P = 0.51, P = 0.80, P = 0.66, P = 0.09 respectively) and right (P = 0.79, P = 0.45, P = 0.56, P = 0.11 respectively). The number and distribution of perforators were then compared with commonly used anatomical texts. CONCLUSION: As in other parts of the body, textbook descriptions of anatomical structures may not be reflected consistently in vivo. However, the perforating branches of the profunda femoris demonstrate a predictable topographical relationship to palpable bony landmarks.

Effects of Tongmai oral liquid in femoral ateriovenous fistula.

BACKGROUND: This study was conducted to investigate the protective effect of Tongmai oral liquid on arteriovenous fistula function and to provide an effective method to promote fistula maturation. METHODS: Fifteen female and fifteen male SPF New Zealand rabbits were randomly allocated into 3 groups including control, Aspirin and Tongmai oral liquid groups. A side-to-side femoral arteriovenous fistula was established in each rabbit and then animals were treated with Aspirin or Tongmai oral liquid for 2 weeks. The concentrations of circulating ET-1 and NO were determined before and after operation (on preoperative day, operative day, post-D1, post-D3, post-D7 and post-D15), respectively. Blood flow of the fistula stoma and contralateral artery and vein was determined on the 15th postoperative day. Last, the fistula stoma was dissected to observe patency, thrombosis and adhesion with surrounding tissues. RESULTS: 28 rabbits survived during the surgical process and the following 15-day observational period. Tissue adhesion of arteriovenous fistula with surrounding tissues was improved and fistula thrombosis was reduced by treatment with Tongmai oral liquid. NO concentration decreased to a different extent after vascular surgery. Tongmai oral liquid failed to regulate the equilibrium between NO and ET-1, but it improved blood flow of fistula stoma, as compared to control and Aspirin groups. Blood flow of fistula stoma in the three groups was lower than that of the contralateral femoral artery. CONCLUSIONS: Tongmai oral liquid improved the function of femoral ateriovenous fistula in the rabbit model by increasing blood flow and reducing thrombosis, probably not by regulating the dynamic equilibrium between NO and ET-1.

Vascular variations of the transverse upper gracilis flap in consideration for breast reconstruction.

PURPOSE: The transverse upper gracilis (TUG) myocutaneous flap has served as an alternative to abdominally based autologous breast reconstruction since its introduction by Yousif et al in 1992. The reliability of the overlying skin paddle of the gracilis myocutaneous flap depends on the perforator anatomy as well as the vascular pedicle. Although much attention recently has been given to variations in the septocutaneous as well as myocutaneous perforators, we believe that relevant variations in pedicle anatomy have been underappreciated. We would like to report our experience with pedicle variability. METHODS: A retrospective review of records was performed on patients undergoing a TUG flap for autologous breast reconstruction from July 2006 and November 2011 by a single surgeon (L.C.W.). RESULTS: A total of 36 TUG flaps were performed on 24 patients. Twelve patients underwent bilateral simultaneous TUG reconstruction, and 12 patients underwent unilateral TUG reconstruction. Pedicle variability was found in 6 (17%) of 36 dissections. In 5.5% of dissections, there was a split pedicle and 11% were found to have a double main pedicle. There was 1 partial flap loss that resulted in a failed breast reconstruction. Four limbs had some degree of resultant lymphedema as a consequence of flap harvest. CONCLUSIONS: Although still a viable alternative to abdominally based autologous reconstruction, we find that the variability of the main pedicle has been quite underestimated in earlier reports. We also present a logical algorithm for flap dissection when the microsurgeon encounters such aberrancies.

Lower limb overflow syndrome in extracorporeal membrane oxygenation.

Peripheral extracorporeal membrane oxygenation (ECMO) is associated with a not negligible rate of vascular morbidity. Most vascular complications are related to limb ischaemia mainly due to insufficient limb perfusion or embolic events. To the best of our knowledge, this is the first report of a severe epidermolysis and overflow syndrome as a result of an overperfusion phenomenon through an unknown femoral arterio-venous fistula in a patient requiring ECMO support.

Treatment of a massive left femoral arteriovenous malformation using an innovative modular hybrid bifurcated stent graft system.

BACKGROUND: Arteriovenous malformations (AVMs) are difficult to treat and manage because of their high recurrence and complication rates. In particular, peripheral AVMs pose multiple clinical challenges because of their high flow rates and the frequent presence of multifocal nidi. METHODS: A 37-year-old man with a massive AVM involving the left common, deep, and superficial femoral arteries and veins is discussed herein. After initially being treated at another facility with coil embolization in 2005, he went untreated until he presented to us in April 2012 with swelling, tissue breakdown, leg ulcers, pain, and difficulty walking. When our extensive packed coil embolization proved ineffective, we knew that other standard treatments would be impractical, given the size of the AVM. Because the patient was in significant danger of bleeding, we treated him endovascularly with a system of modified stent grafts to exclude the arterial branches feeding multiple nidi. RESULTS: Postoperative computed tomography angiography scans revealed exclusion of the AVM and excellent flow to the deep and superficial femoral arteries. At 6 months postoperatively, the patient had no complications, and the leg continued to decompress. At 8 months postoperatively, we started additional treatment using percutaneous sclerotherapy to treat residual areas. CONCLUSION: A modular hybrid bifurcated stent graft system is a viable option to treat or manage complex peripheral arteriovenous malformations.

Duplicated common femoral artery can be safely cannulated for femorofemoral cardiopulmonary bypass.

The duplicated common femoral artery can be safely cannulated for femorofemoral bypass, but we recommend postoperative imaging to identify potential complications. We found no previous reports of duplicated common femoral artery.

Unusual branches of femoral artery in the femoral triangle: a case report / Ramas inusuales de la arteria femoral en el triángulo femoral: reporte de caso

Femoral artery is the major artery of the lower limb. It shows some variations in its branching pattern. One of the rare but clinically important variations is the origin of deep circumflex iliac and inferior epigastric arteries from it instead of from external iliac artery. We report here the origin of inferior epigastric and deep circumflex iliac arteries from the femoral artery bilaterally. Both the arteries passed up deep to the inguinal ligament and had a normal course and distribution after crossing the inguinal ligament. Knowledge of these variations is of importance in plastic surgery, anterior approach to the hip joint, draining psoas abscess or reducing a femoral hernia.

La arteria femoral es la principal arteria del miembro inferior. Se observan algunas variaciones en su patrón de ramificación. Una variante rara, pero clínicamente importante es el origen común de las arterias circunfleja iliaca profunda y epigástrica inferior no desde la arteria ilíaca externa. Presentamos el origen bilateral de las arterias epigástricas inferiores y circunfleja ilíaca profunda desde la arteria femoral. Ambas arterias pasaron profundas al ligamento inguinal y tuvieron un curso y distribución normal después de cruzar el ligamento inguinal. El conocimiento de estas variaciones son de importancia en la cirugía plástica, en el acceso anterior a la articulación de la cadera, el drenaje absceso del músculo psoas mayor o para reducir una hernia femoral.

Unusual branching pattern of external iliac artery: case report / Patrón inusual de ramificación de la arteria ilíaca externa: reporte de caso

During the routine dissection, a rare anomaly was observed in left lower limb of a female cadaver. The external iliac artery continued as femoral artery, branched on lateral side as the lateral circumflex femoral artery and on medial side as profunda femoris artery. On tracing the lateral circumflex femoral artery, the ascending branch towards the spinous anastomosis was very thin and coursed behind the rectus femoris muscle. The transverse and descending branches were not observed, however, the artery coursed along the vastus lateralis towards the knee. The femoral artery had its normal course and continued as popliteal artery. The profunda femoris artery originated from the medial side of the external iliac artery, initially superficial to the femoral vein, coursed downwards and posteriorly, relating posteromedial to femoral artery. The medial circumflex femoral artery originated as thin branch, which further divided into two divisions. The profunda femoris gave origin of 3 perforators and continued as 4th perforator. The unusual branching pattern was observed to be novel and not reported in the literature.

Durante una disección de rutina, se observó una rara anomalía en el miembro inferior izquierdo de un cadáver de sexo femenino. La arteria ilíaca externa dio origen en el lado lateral ala arteria circunfleja femoral lateral y en el lado medial a la arteria femoral profunda. En el recorrido de la arteria circunfleja femoral lateral, la rama ascendente era muy delgada y corría detrás del músculo recto femoral. No se observaron ramas transversales y descendente, sin embargo, la arteria descendió hacia la rodilla a lo largo del músculo vasto lateral. La arteria femoral tuvo su curso normal y continuó como arteria poplítea. La arteria femoral profunda, inicialmente superficial a la vena femoral, se dirigió inferior y posteriormente colocándose posteromedial a la arteria femoral. La arteria circunfleja femoral medial se originó como una rama delgada, que otorgó dos arterias. La arteria femoral profunda dio origen a tres ramas perforantes y continuó como cuarta perforante. Este patrón de ramificación inusual es una descripción nueva no reportada en la literatura.

[Combined methods of treatment the congenital arterio-venous fistulas of peripheral vessels].

A 10-year experience and results of combined methods of surgical treatment of arterio-venous fistulas of peripheral vessels in 50 patients were analyzed. The patients were systematized on the basis of existing classifications, clinical manifestations of the disease, methods of invasive (ultrasound dopplerography and duplex scanning) and invasive (angiography) examinations. According to many authors no one of conventional methods of surgical treatment of arterio-venous fistulas which are used singly can be effective and must not be recommended as the most optimal. Stepwise employing of traditional operations and endovascular techniques are the main conditions for preventive measures of ischemic disorders in the limbs.

Persistent sciatic artery aneurysm.

A persistent sciatic artery (PSA) is an exceptionally rare embryologic vascular anomaly with a reported incidence of 0.01-0.05% based on angiography. Most PSAs do not require treatment and 50% of affected individuals are asymptomatic. However, all PSA-related aneurysms should be treated because they involve a high risk of complications.We report the case of 53-year-old man with a 7-cm aneurysm arising from a left dominant PSA together with a hypoplastic left femoral artery, who presented with acute left limb ischemia. The patient had realized the presence of a pulsating mass in his left buttock 12 months before the ischemic event. He was treated initially with below-knee popliteal embolectomy and exclusion of the aneurysm with 2 overlapping, self-expanding, 10×50-mm stent grafts. On diagnosis, PSA aneurysms require neither potentially harmful ligation nor a technically challenging open procedure. Endovascular aneurysm exclusion using an antegrade or a retrograde approach is safe and efficient; however, long-term follow-up is required to establish the efficacy of this endovascular procedure.

[The persistent sciatic artery aneurysm. A rare and painful buttock mass]. / Anévrisme de l'artère sciatique persistante. Une cause rare de masse fessière douloureuse.

The persistent sciatic artery is a rare cause of painful buttock mass with L5-S1 radicular signs. A 56-year-old man presents a right painful buttock mass with L5-S1 radicular symptoms for 3 years. The surgical exploration found a pulsatile vascular mass like a persistent sciatic artery aneurysm. This vascular pathology is a misunderstood embryogenesis anomaly. The treatment aims to avoid serious complications. This pathology must be known from plastic surgeon.

Anomalous high bifurcation of the common femoral artery at the groin: management of GSV incompetence with endovenous laser ablation.

OBJECTIVES: To discuss safety of EVLA in anomalies of the GSV anatomy. To review and discuss complications of surgery involving anomalous anatomy. METHOD: We report a case of high bifurcation of the common femoral artery wrapping around the saphenofemoral junction. RESULTS: Successful ablation was achieved with no adverse consequences. CONCLUSION: EVLA is a safe treatment for SFJ/GSV incompetence in the presence of vascular anomalies that have historically resulted in serious vascular complications from surgery.

Surgical treatment for a complex congenital arteriovenous malformation of the lower limb.

Arteriovenous fistula is defined as an abnormal communication between the arterial and venous systems. The complexity of congenital arteriovenous malformations makes treatment challenging. We present the case of a 23-year-old woman who had a complex congenital arteriovenous malformation in her left leg and a history of 2 unsuccessful coil-embolization procedures. We ligated all the feeding arteries of the arteriovenous malformation in the region of the superficial femoral artery, and the surgery was successful without sequelae. The patient returned 2 years later with thrombosis of the great saphenous vein and underwent a second operation. The thrombosed vein and all varicosities were excised successfully. Surgery can be an effective method for correcting complex congenital arteriovenous malformations, especially in the lower limbs. A 2-staged surgical approach like ours might be a good option in suitable patients.