Abnormal Vasculature Development in Zebrafish Embryos with Reduced Expression of Pantothenate Kinase 2 Gene.

Mutations in pank2 gene encoding pantothenate kinase 2 determine a pantothenate kinase-associated neurodegeneration, a rare disorder characterized by iron deposition in the globus pallidus. To extend our previous work, we performed microinjections of a new pank2-specific morpholino to zebrafish embryos and thoroughly analyzed vasculature development. Vessels development was severely perturbed in the head, trunk, and tail, where blood accumulation was remarkable and associated with dilation of the posterior cardinal vein. This phenotype was specific as confirmed by p53 expression analysis and injection of the same morpholino in pank2-mutant embryos. We can conclude that pank2 gene is involved in vasculature development in zebrafish embryos. The comprehension of the underlining mechanisms could be of relevance for understanding of pantothenate kinase-associated neurodegeneration.

Tmem2 Regulates Embryonic Vegf Signaling by Controlling Hyaluronic Acid Turnover.

Angiogenesis is responsible for tissue vascularization during development, as well as in pathological contexts, including cancer and ischemia. Vascular endothelial growth factors (VEGFs) regulate angiogenesis by acting through VEGF receptors to induce endothelial cell signaling. VEGF is processed in the extracellular matrix (ECM), but the complexity of ECM control of VEGF signaling and angiogenesis remains far from understood. In a forward genetic screen, we identified angiogenesis defects in tmem2 zebrafish mutants that lack both arterial and venous Vegf/Vegfr/Erk signaling. Strikingly, tmem2 mutants display increased hyaluronic acid (HA) surrounding developing vessels. Angiogenesis in tmem2 mutants was rescued, or restored after failed sprouting, by degrading this increased HA. Furthermore, oligomerized HA or overexpression of Vegfc rescued angiogenesis in tmem2 mutants. Based on these data, and the known structure of Tmem2, we find that Tmem2 regulates HA turnover to promote normal Vegf signaling during developmental angiogenesis.

Reliability of eccentric position of the pedicle instead of central position in a thoracodorsal artery perforator flap.

INTRODUCTION: To obtain longer vascular pedicle in perforator flaps, surgeons often use eccentrically rather than centrally located perforators. The aim of this study was to compare the safety and reliability of thoracodorsal artery perforator (TDAP) flaps harvested with centrally or eccentrically located perforators. METHODS: Between January 2008 and March 2012, 100 TDAP flaps were used to reconstruct the lower extremity defects. Flaps longer than 10 cm, with a single musculocutaneous perforator, and one artery-one vein anastomoses were included. The cases were divided into two groups according to perforator location; Central perforators in 60 cases (group 1), and peripheral perforators in 40 cases (group 2). Total pedicle length was between the points where the perforator enters the flap to the end of the pedicle. Real pedicle length was from flap margin to the end of the pedicle. The flap dimension, total pedicle length, real pedicle length, and flap related complications were measured. RESULTS: The flaps were smaller in group 1 than in group 2 (159.6 ± 94.08 vs.189.95 ± 134.30 cm2 , P = 0.455). Total pedicle length was almost the same (12.12 ± 1.57 vs.12.88 ± 2.10 cm, P = 0.420), but the mean real pedicle length was longer in group 2 (6.13 ± 1.33 vs.11.65 ± 2.08 cm, P < 0.05). There were 4 cases of partial loss of flap in group 1 and 3 partial loss and one total flap loss in group 2 without significant difference (P = 0.547). CONCLUSIONS: Using eccentrically located perforators is simple method of extending real pedicle length, but there have been concerns regarding flap perfusion and distal vascularity. Our findings suggest that, in TDAP flaps, both eccentric and central perforator are safe options. © 2014 Wiley Periodicals, Inc. Microsurgery 37:44-48, 2017.

SimLife a new model of simulation using a pulsated revascularized and reventilated cadaver for surgical education.

INTRODUCTION: Alike becoming a pilot requires competences, acquisition of technical skills is essential to become a surgeon. Halsted's theory on surgical education "See one, do one, and teach one" is not currently compatible with the reality of socio-economic constraints of the operating room, the patient's safety demand and the reduction of residents' work hours. MATERIEL AND METHODS: In all countries, this brings mandatory to simulation education for surgery resident's training. Many models are available: video trainers or pelvi-trainers, computed simulator, animal models or human cadaver… Human cadaveric dissection has long been used to teach surgical anatomy. RESULTS: Surgery on human cadaveric model brings greatest accuracy to the haptic characteristics of surgical procedures. Learning in an appropriate and realistic simulation context increases the level of acquisition of the residents' skills and reduces stress and anxiety when performing real procedures. CONCLUSION: We present a technique of perfusion and ventilation of a fresh human cadaver that restores pulsatile circulation and respiratory movements of the model.

[THE METHOD CHOICE OF OPERATIVE INTERVENTION IN PATIENTS WITH POSTTRAUMATIC DEFECTS OF COVERING TISSUES OF TRUNK AND EXTREMITIES].

Results of 242 patients treatment, suffering the trunk and extremities covering tissues defects, which have had occur as a consequence of mechanical injury in a 2008 ­ 2016 yrs period, were analyzed. There were 697 оperative interventions performed, of them 492 (70.6%) ­ aiming to restore the tissues injured. The choice of method of the correcting intervention and the tissues defects covering have depended upon the wound dimension and depth, as well as peculiarities of hemodynamics in the area injured. Application of differentiated approach to choice of method for the wound surfaces closure, which were created as a consequence of mechanical injury, have had permitted to achieve satisfactory results in 98.75% of patients.

[Reconstruction of trunk soft-tissue defect using the propeller flaps based on the perforators of the posterior intercostal artery ].

Objective: To explore the feasibility and technical tips of the posterior intercostal artery perforator (PICAP) flaps for trunk defect reconstruction. Methods: The PICAPs were thoroughly explored with the hand-held ultrasound Doppler.According to the size,shape and location of the defect,a perforator flap was raised based on the chosen PICAP,rotated in a certain degree and used to reconstruct the torso defect. Results: From October 2009 to October 2015,22 patients underwent defect reconstruction using the PICAP propeller flaps.The chosen perforators derived from the vertebral segments of the posterior intercostal arteries in 2 patients,from costal groove segments in 15,from intermuscular segments in 4,and from subcostal artery in 1.The skin paddle dimension ranged from 12 cm × 4 cm-30 cm × 10 cm.The length of the perforator pedicle was 3.5-7.0 cm (average 4.8 cm).The flaps were rotated 180° in 15 patients,150° in 4 patients,and 90° in 3 patients.19 flaps survived completely.Distal partial flap necrosis occurred in two flaps and total flap necrosis in one.All wounds at donor sites were closed directly.The patients were followed up for 1 to 5 years (average 3.5 years) with satisfactory outcomes and no tumor recurrence. Conclusions: The PICAP propeller flap provides a valuable option for different torso defects reconstruction.

Intercostal artery perforator propeller flap for reconstruction of trunk defects following sarcoma resection.

Trunk defects following soft tissue sarcoma resection are usually managed by myocutaneous flaps or free flaps. However, harvesting muscle will cause functional morbidities and some trunk regions lack reliable recipient vessels. The intercostal arteries give off multiple perforators, which distribute widely over the trunk and can supply various pedicle flaps. Our purpose is to use various intercostal artery perforator propeller flaps for trunk oncologic reconstruction. Between November 2013 and July 2014, nine intercostal artery perforator propeller flaps were performed in seven patients to reconstruct the defects following sarcoma resection in different regions of the trunk, including the back, lumbar, chest, and abdomen. Two perforators from intercostal arteries were identified for each flap using Doppler ultrasound probe adjacent to the defect. The perforator with visible pulsation was chosen as the pedicle vessel. An elliptical flap was raised and rotated in a propeller fashion to repair the defects. There were one dorsal intercostal artery perforator flap, four dorsolateral intercostal artery perforator flaps, three lateral intercostal artery perforator flaps, and one anterior intercostal artery perforator flap. The mean skin paddle dimension was 9.38 cm in width (range 6-14 cm) and 21.22 cm in length (range 13-28 cm). All intercostal artery perforator flaps survived completely, except for marginal necrosis in one flap harvested close to the previous flap donor site. The intercostal artery perforator propeller flap provides various and valuable options in our reconstructive armamentarium for trunk oncologic reconstruction. To our knowledge, this is the first case series of using intercostal artery perforator propeller flaps for trunk oncologic reconstruction and clinical application of dorsolateral intercostal artery perforator flaps.

Supermicrosurgical free sensate intercostal artery perforator flap based on the lateral cutaneous branch for plantar reconstruction.

The use of an intercostal artery perforator (ICAP) flap has recently become popular in reconstructive surgery. We have developed a novel free sensate ICAP flap based on the lateral cutaneous branch (LCB) and applied it to a case with a plantar defect. To the best of our knowledge, this case is the first to describe a free sensate ICAP flap based on the LCB. This method has several advantages: (1) a sensate flap is possible because the LCB neurovascular bundle is consistently available; (2) the long neurovascular pedicle can be harvested in the supine position without the risk of pneumothorax; (3) the donor-site morbidity is low; and (4) conversion or combination with a superficial circumflex iliac artery perforator (SCIP) or a superficial inferior epigastric artery (SIEA) flap is readily possible. We believe that this method represents a new option for soft-tissue reconstruction.

Report of a rare case: occult hemothorax due to blunt trauma without obvious injury to other organs.

Traumatic hemothorax commonly occurs accompanied by organ damage, such as rib fractures, lung injury and diaphragm rupture. Our reported patient was a 61-year-old man who fell down from a stepladder about 1 meter in height, resulting in a heavy blow to the left abdomen. He consulted a clinic because of left chest pain the next day and was transported to the emergency center of our hospital on diagnosis of hemothorax with hemorrhagic shock.On computed tomography scanning with contrast medium, left hemothorax without rib fracture, diaphragm rupture or obvious organ injury was evident. We found only bleeding to the thoracic space from a branch of the left inferior phrenic artery without involvement of the abdomen. The patient underwent percutaneous angiography and embolization for hemostasis, and subsequently thoracotomy in order to check the active bleeding and remove the hematoma to improve respiratory. As thoracotomy findings, we found damage of a branch of the left inferior phrenic artery to the thoracic space without diaphragm rupture, and sutured the lesion. Such active intervention followed by surgical procedures was effective and should be considered for rare occurrences like the present case. We must consider not only traumatic diaphragm rupture, but also vascular damage by pressure trauma as etiological factors for hemothorax.

Morphometric analysis of torso arterial anatomy with implications for resuscitative aortic occlusion.

BACKGROUND: Hemorrhage is a leading cause of death in military and civilian trauma. Despite the importance of the aorta as a site of hemorrhage control and resuscitative occlusion, detailed knowledge of its morphometry is lacking. The objective of this study was to characterize aortic morphometry in a trauma population, including quantification of distances as well as and diameters and definition of relevant aortic zones. METHODS: Center line measures were made (Volume Viewer) from contrast computed tomography (CT) scans of male trauma patients (18-45 years). Aortic zones were defined based on branch arteries. Zone I includes left subclavian to celiac; Zone II includes celiac to caudal renal; Zone III includes caudal renal to aortic bifurcation. Zone lengths were calculated and correlated to a novel external measure of torso extent (symphysis pubis to sternal notch). RESULTS: Eighty-eight males (mean [SD], 28 [4] years) had CT scans for the study. The median (interquartile range) lengths (mm) of Zones I, II, and III were 210 mm (202-223 mm), 33 mm (28-38 mm), and 97 mm (91-103 mm), respectively. Median aortic diameters at the left subclavian, celiac, and lowest renal arteries were 21 mm (20-23 mm), 18 mm (16-19 mm), and 15 mm (14-16 mm), respectively, and the terminal aortic diameter was 14 mm (13-15 mm). The correlation of determination for descending aortic length (all zones) against torso extend was r = 0.454. CONCLUSION: This study provides a morphometric analysis of the aorta in a male population, demonstrating consistency of length and diameter while defining distinct axial zones. Findings suggest that center line aortic distances correlate with a simple, external measure of torso extent. Morphometric study of the aorta using CT data may facilitate the development and implementation of occlusion techniques to manage noncompressible torso, pelvic, and junctional femoral hemorrhage.

The epidemiology of noncompressible torso hemorrhage in the wars in Iraq and Afghanistan.

BACKGROUND: Noncompressible torso hemorrhage (NCTH) is the leading cause of potentially survivable trauma in the battlefield and has recently been defined using anatomic and physiologic criteria. The objective of this study was to characterize the frequency and mortality in combat of NCTH using a contemporary definition. METHODS: Four categories of torso injury, each based on vascular disruption, were identified in US military casualties from the Department of Defense Trauma Registry (2002-2010): (1) thoracic, including lung; (2) solid organ (high-grade spleen, liver, and kidney); (3) named axial vessel; and (4) pelvic fracture with ring disruption. Injuries within these categories were evaluated in the context of physiologic indicator of shock and/or the need for operative hemorrhage control. RESULTS: Of 15,209 battle injuries sustained during the study period, 12.7% (n = 1,936) had sustained one or more categories of torso injury. Of these, 331 (17.1%) had evidence of shock or the need for urgent hemorrhage control, with a mean (SD) Injury Severity Score (ISS) and mortality rate of 30 (13) and 18.7%, respectively. Pulmonary injuries were most numerous (41.7%), followed by solid-organ (29.3%), vascular (25.7%), and pelvic (15.1%) injuries. Following multivariate analysis, the most mortal injury complexes were identified as major arterial injury (odds ratio, 3.38; 95% confidence interval, 1.17-9.74) and pulmonary injury (odds ratio, 2.23; 95% confidence interval, 1.23-4.98). CONCLUSION: NCTH can be defined using anatomic parameters combined with physiologic and operative interventions suggestive of hemorrhage. Major arterial and pulmonary injuries contribute most significantly to the mortality burden. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

[Operative access routes in reconstructive vascular surgery of arteries. Part 1: neck and torso]. / Operative Zugangswege in der rekonstruktiven Gefäßchirurgie der Arterien. Teil 1: Hals und Rumpf.

Exact knowledge of the topographical anatomy of the arterial vascular system is the basis for all access routes. This article describes the most important assess routes in the neck and torso regions and gives an overview of the basic principles of the surgical technique with respect to suture material, suture technique, anastomotic technique and the atraumatic preparation of the anastomosis region. The article makes no claims to completeness because this would overstretch the limits but refers in particular to the references listed.

'In parallel' interconnectivity of the dorsal longitudinal anastomotic vessels requires both VEGF signaling and circulatory flow.

Blood vessels deliver oxygen, nutrients, hormones and immunity factors throughout the body. To perform these vital functions, vascular cords branch, lumenize and interconnect. Yet, little is known about the cellular, molecular and physiological mechanisms that control how circulatory networks form and interconnect. Specifically, how circulatory networks merge by interconnecting 'in parallel' along their boundaries remains unexplored. To examine this process we studied the formation and functional maturation of the plexus that forms between the dorsal longitudinal anastomotic vessels (DLAVs) in the zebrafish. We find that the migration and proliferation of endothelial cells within the DLAVs and their segmental (Se) vessel precursors drives DLAV plexus formation. Remarkably, the presence of Se vessels containing only endothelial cells of the arterial lineage is sufficient for DLAV plexus morphogenesis, suggesting that endothelial cells from the venous lineage make a dispensable or null contribution to this process. The discovery of a circuit that integrates the inputs of circulatory flow and vascular endothelial growth factor (VEGF) signaling to modulate aortic arch angiogenesis, together with the expression of components of this circuit in the trunk vasculature, prompted us to investigate the role of these inputs and their relationship during DLAV plexus formation. We find that circulatory flow and VEGF signaling make additive contributions to DLAV plexus morphogenesis, rather than acting as essential inputs with equivalent contributions as they do during aortic arch angiogenesis. Our observations underscore the existence of context-dependent differences in the integration of physiological stimuli and signaling cascades during vascular development.

Torso vascular trauma at an urban level-I trauma center.

Injuries to the great vessels of the torso are commonly seen and managed in busy urban trauma centers. This same injury complex is rarely seen in military conflicts, likely because of the high kinetic energy of weapons causing the wounds seen in this setting. Although most of the great advancements in trauma surgery over the past century have generally resulted from our wartime experience, civilian centers have contributed greatly to the understanding and management of torso vascular injuries. This article reviews the presentation and management of injuries to the great vessels of the torso from major penetrating and blunt trauma.