The free Thenar flap for thumb pulp reconstruction: A case report.

The thumb is acknowledged to contribute significantly to hand function, accounting for up to 40% of its overall capability. Consequently, injuries affecting the thumb can have a profound impact on the quality of life experienced by patients. When it comes to the surgical reconstruction of thumb injuries, the primary objective is to promptly provide coverage of the affected area with glabrous skin, thus preserving both the length and functionality of the thumb. Managing injuries specifically involving the thumb pulp can be particularly challenging due to the digit's size and vital role. Acquiring an adequate amount of glabrous soft tissue poses a difficulty in such cases. Various reconstructive approaches, encompassing a range of options on the reconstructive ladder, have been documented for thumb pulp injuries. The most popular options include pedicled flaps and free flaps obtained from both the hands and feet. However, a consensus regarding the optimal method for reconstructing the thumb pulp has yet to be reached. We present a case of total thumb pulp reconstruction for a 40 × 30 mm defect using the free thenar flap in a 65-year-old carpenter who sustained a work-related injury. This flap was designed and raised on the superficial branch of the radial artery with a single subcutaneous vein and a branch of the palmar cutaneous nerve, the flap measured 43 × 32 mm. It was inset transversely with an end-to-end arterial anastomosis to the ulnar digital artery, venous anastomosis to the dorsal digital vein and nerve coaptation to the ulnar digital nerve. The postoperative course was uneventful, and the patient was discharged the following day without any complications. Eight months after surgery, the patient was extremely satisfied with the results of the procedure in terms of both function and appearance. The patient had experienced an improvement in function, sensation, and aesthetics. The patient had a QuickDASH disability/symptom score of 15.91 and a QuickDASH work module score of 18.75; the range of motion in the treated thumb was almost the same as the opposite thumb. The patient successfully resumed work three weeks following the procedure, initially with modified duties, and fully regained their work capacity within six weeks. As the patient's primary concern was their ability to return to work, the utilization of a free thenar flap offered several distinct advantages. These included minimal post-operative complications, facilitated by a single operative site, allowing for reconstruction under regional anesthesia. Moreover, the procedure was conducted in a single stage, enabling the patient to be discharged on the same day without the need for further procedures. Furthermore, similar to several other reconstructive options for the thumb, the utilization of a free thenar flap offered the advantage of providing high-quality, like-for-like glabrous tissue.

Relationship between Serum YKL-40 Level and Forearm Arterial Patency after Repair.

BACKGROUND: The study aimed to assess the effects of serum YKL-40 level on patency at the repair site in patients who underwent arterial repair at the level of the forearm. METHODS: The study included 58 subjects, including 29 patients (aged 18-50 years) who had ulnar or radial artery injury secondary to cut injury to wrist between June 2015 and November 2019 and no comorbid disease and 29 age- and sex-matched healthy controls. The vascular patency was assessed using Doppler sonography in patients who underwent arterial repair at the level of the forearm. The patients were defined as flow failure if the blood flow was ≤50%, and sufficient flow if the blood flow was >50% of those in the synonymous artery on the intact extremity. The YKL-40 level differences in the patient and control groups were compared to those in the sufficient and insufficient flow groups. RESULTS: The patients were stratified into 2 groups based on the presence of sufficient flow. The mean YKL level was 11.96 ± 8.87 in the sufficient flow groups, whereas it was 32.22 ± 15.43 in the insufficient flow groups (p= 0.038). Besides, it was found that each unit of increase in the YKL-40 level increased the likelihood of having flow failure by 1.128. CONCLUSION: Based on our results, it was observed that over-expression of the YKL-40 level has adverse effects on patency following arterial repair.

Is the dorsal vascular system sufficient to vascularize the entire teguments of the thumb?

PURPOSE: Simultaneous lesions of both proper digital arteries of the thumb are common in hand trauma surgery. The purpose of this anatomical study was to determine if the dorsal arterial network could be sufficient to ensure the vascularization of the thumb skin sheath. METHODS: We carried out a cadaveric study on 22 hands. The ulnar and radial proper digital arteries of the thumb were ligated at the base of the first phalanx. Red dye was injected into the radial artery and blue dye into the ulnar artery at the wrist level. Visual evaluation of skin staining and systematic photographs was done at 1, 3 and 10 min after injection of dyes. RESULTS: Staining of the thumb sheath was obtained in 100% of the dissections and complete in 91.91% of cases. Staining originated from mixed radial and ulnar artery origins in 81.82% of cases. It was incomplete in 9.09% of cases with a missing on the dorsoradial edge of the proximal phalanx. In one dissection, the whole hand skin was only stained red, and in another dissection only stained blue. CONCLUSION: The dorsal vascular network ensures the substitution of the skin vascularization in more than 90% of cases when ligating the proper digital arteries of the thumb. A clinical impression of good skin vascularization after injury of both proper digital arteries might lead the surgeon not to perform systematic revascularization, but the risk of variable damages of adjacent tissues due to an interruption of one major arterial system requires a palmar arterial anastomosis whenever possible.

Bypass surgery in a mangled forearm using an intramedullary tunnel through the radius.

Critical ischemia in the upper extremity is rare. A surgical bypass is thought to be the superior treatment option. We describe a rare case where regular tunneling options of the bypass were not available and an intramedullary tunnel was used.

Variation in the outer diameter of vascular sheaths commonly used in infant cardiac catheterization.

OBJECTIVE: To compare the outer diameter (OD) of conventional and radial sheaths from different manufacturers for sizes typically used in infant catheterization. BACKGROUND: The smallest sheath size is recommended to minimize risk of arterial injury in infants. However, sheath size refers to its internal diameter (ID), but it is the larger OD that determines risk. The OD varies between manufacturers and is frequently not known to the end user. METHODS: Three authors measured the OD of 3, 3.3, 4, 5, and 6 French (Fr) sheaths from different manufacturers using a Mitutoyo digital micrometer. Continuous variables are reported as mean ± SD. The midshaft and proximal-shaft sheath measurements were compared using an independent samples t test. Agreement between author measurements was tested using intra- and inter-rater reliability analysis. Manufacturer sheath OD measurements were obtained. Statistical significance was set at p < .05. RESULTS: There was no difference in the measured sheath diameters at the midpoint and proximally (p < .05). The intra-rater and inter-rater reliability were excellent (Intraclass correlation coefficient 1.0). Among conventional sheaths the OD varied between manufacturers, Terumo sheaths had the smallest and Galt sheaths had the largest OD. Radial sheaths had the smallest OD (1 Fr smaller) when compared to similar sized conventional sheaths. For instance, the OD of 4 Fr radial sheath (1.610 ± 0.006 mm) is essentially the same as the OD of the conventional 3 Fr (1.644 ± 0.016 mm) and 3.3 Fr (1.635 ± 0.005 mm) sheaths. CONCLUSIONS: Our study shows variation in the OD of sheaths used in infant catheterization. The radial sheaths offer the smallest OD across sizes.

Procedural and clinical performance of dual- versus single-catheter strategy for transradial coronary angiography: A meta-analysis of randomized trials.

OBJECTIVES: We sought to compare the procedural and clinical performance of dual- versus single-catheter strategy for transradial coronary angiography. BACKGROUND: The radial artery (RA) is recommended as the vascular access of choice in patients undergoing coronary angiography and intervention. The procedural and clinical performance of dual- versus single-catheter strategy in patients undergoing transradial coronary angiography remains a matter of debate. METHODS: This is a study-level meta-analysis of randomized trials. The primary outcome was procedure time. The main secondary outcome was fluoroscopy time. Other outcomes of interest were contrast volume, crossover to other catheter strategy and RA spasm. RESULTS: A total of 2,062 patients (978 randomly assigned to dual-catheter and 1,084 to single-catheter strategy) included in seven trials were available for the quantitative synthesis. A dual-catheter strategy was associated with procedure time (standardized mean difference [95% confidence intervals (CI)], 0.55 [-0.69, 1.78]; p = .32), fluoroscopy time (-0.36 [-2.39, 1.67]; p = .68) and contrast volume (-0.93 [-3.79, 1.94]; p = .44) comparable to a single-catheter strategy. The risk for crossover was lower (risk ratio [95% CI], 0.14 [0.03, 0.70]; p = .025) while the risk for RA spasm was higher (1.81 [1.54, 2.12]; p < .001) among patients assigned to dual- versus single-catheter strategy. CONCLUSIONS: This meta-analysis provides evidence for a comparable procedural performance of either dual- or single-catheter strategy for transradial coronary angiography. The fewer crossovers with dual-catheter strategy occur at the expense of more frequent radial artery spasm.

Effects of Cross-Clamping on Vascular Mechanics: Comparing Waveform Analysis With a Numerical Model.

BACKGROUND: Immediate changes in vascular mechanics during aortic cross-clamping remain widely unknown. By using a numerical model of the arterial network, vascular compliance and resistance can be estimated and the time constant of pressure waves can be calculated and compared with results from the classic arterial waveform analysis. METHODS: Experimental data were registered from continuous invasive radial artery pressure measurements from 11 patients undergoing vascular surgery. A stable set of beats were chosen immediately before and after each clamping event. Through the arterial waveform analysis, the time constant was calculated for each individual beat and for a mean beat of each condition as to compare with numerical simulations. Overall proportional changes in resistance and compliance during clamping and unclamping were calculated using the numerical model. RESULTS: Arterial waveform analysis of individual beats indicated a significant 10% median reduction in the time constant after clamping, and a significant 17% median increase in the time constant after unclamping. There was a positive correlation between waveform analysis and numerical values of the time constant, which was moderate (ρ = 0.51; P = 0.01486) during clamping and strong (ρ = 0.77; P ≤ 0.0001) during unclamping. After clamping, there was a significant 16% increase in the mean resistance and a significant 23% decrease in the mean compliance. After unclamping, there was a significant 19% decrease in the mean resistance and a significant 56% increase in the mean compliance. CONCLUSIONS: There are significant hemodynamic changes in vascular compliance and resistance during aortic clamping and unclamping. Numerical computer models can add information on the mechanisms of injury due to aortic clamping.

Role of vascular ultrasound scanning in repeated trans-radial coronary artery intervention (prospective randomized study).

OBJECTIVES: We aimed to detect if pre-procedure vascular ultrasound scanning (VUS) of radial arteries (RAs) can increase the radial access success (RAS) rate and/or reduce the vascular access time (VAT), by guiding the choice of the proper access site for repeated trans-radial interventions (TRIs). BACKGROUND: Currently, repeated-TRIs are encountered more frequently in most of the cath. labs. However, structural changes of the RAs after TRA may hinder it is usage for repeated-TRI. VUS is the most accurate noninvasive test for assessing RAs, nonetheless, its role in the setting of repeated-TRIs has not been studied before. MATERIAL AND METHODS: We randomly assigned 300 patients undergoing repeated-TRI, to either planning the vascular access site based upon the result of VUS that was performed pre-procedural (group A, 150 patients) or to be left to the operator's discretion (group B, 150 patients). RESULTS: In group A (143/145 [98.6%]), RAS rate was only numerically higher than group B (143/150 [95.3%]), P = 0.08. There was a statistically significant differences between both groups in VAT [(1.25 ± 0.17 min), vs. (4.95 ± 0.87 min) for group A and B, respectively, P = 0.02] and in procedure duration [(37.2 ± 19.8 min) vs. (51.8 ± 18.6 min) for group A and B, respectively, P = 0.04]. RA spasm was more common in group B [18% (27/150)] than group A [2% (3/145)], P = 0.001. CONCLUSION: VUS of RAs prior to repeated-TRI is associated with significant reduction in VAT, procedure duration, RA spasm and a mild increase in the RAS rate.

Ankaferd blood stopper as a new strategy to avoid early complications after transradial procedures: A randomized clinical trial.

BACKGROUND: We planned a three arm randomized study to evaluate the safety and efficacy of a new blood stopper, Ankaferd blood stopper (ABS) along with short-time compression, compared to either short-time compression with conventional sterile gauzes (CSG) or with a TR band after transradial (TRA) procedures. METHODS: The Ankaferd blood stopper as a new strategy to avoid early complications. After transradial procedures (ABS transradial) trial is designed in a prospective, randomized, placebo-controlled fashion and registered with http://clinicaltrials.gov (NCT02982733). Six hundred and thirty patients were randomized into three arms in a 1:1:1 fashion corresponding to three different strategies of patent hemostasis techniques after diagnostic or interventional catheterization. RESULTS: One (0.49%) patient in the CSG group and one patient (0.48%) in the TR Band group developed RAO at the end of the hemostasis, compared with 0 (0%) in the ABS group. At 30 days follow-up none of the groups had any patients with RAO. As a secondary end-points the difference was not statistically significant regarding hematoma among the three groups (P = 0.70). Bleeding during deflation of the TR Band or removal of the elastic bandage occurred in 55 patients (26.96%) in the CSG group and in 56 (27.31%) patients in the TR Band group compared to 19 patients (9.40%) in the ABS group (P < 0.001). CONCLUSION: Ankaferd blood stopper is a promising device for use in patent hemostasis, with no evidence on RAO at short-term or long term and with reduced risk of re-bleeding at the end of hemostasis.

A posttraumatic pseudoaneurysm of the left radial artery as a result of a stab wound in an 8-year-old girl.

Pseudoaneurysms arise from a disruption of arterial wall continuity and are most commonly related to a penetrating trauma, an arterial wall inflammation or iatrogenic causes. They differ from real aneurysms due to a lack of one or more layers of the arterial wall. The frequency of peripheral artery pseudoaneurysms in the upper extremities is less than in the lower extremities and its most common cause is a gunshot or a stab wound. The risk of a rupture is higher than in true aneurysms due to a lack of wall layers, therefore requiring surgical treatment in most cases. Here we describe an unusual case of an 8-year-old girl who presented to the emergency department complaining of swelling and pain in her left distal forearm. One month before admission she experienced a penetrating trauma in the same area due to a self inflicted stab wound. After clinical and duplex ultrasonography evaluation the tumefaction proved to be a posttraumatic pseudoaneurysm of the left radial artery.

Two HEmostasis Methods After TransradIal Catheterization: THEMATIC - protocol for a randomized clinical trial.

OBJECTIVE: Randomized clinical trial protocol to evaluate the incidence of radial artery occlusion with two different arterial compression devices after transradial procedures. METHODS: Barbeau's test will be performed in adults scheduled to undergo transradial interventional procedures. Those with A, B, or C plethysmographic patterns will be selected. At the end of the procedure, patients will be randomly assigned (1:1) to receive patent haemostasis with TR Band™ device or conventional haemostasis with an elastic adhesive bandage. The primary outcome is the incidence of radial artery occlusion. Secondary outcomes are Barbeau's test curve change, additional time to achieve haemostasis, incidence of bleeding at the puncture site, pain severity, development of arteriovenous fistula, radial pseudo aneurysm, any access-site complication requiring vascular surgery intervention and costs between the two devices. DISCUSSION: The results of this trial should provide valuable additional information on the best approach for haemostasis after transradial percutaneous cardiovascular interventions.

Interosseous artery as an access artery in case of late radial artery occlusion.

We report a new technique of arterial access through the ipsilateral interosseous artery in a case of late radial artery occlusion (RAO). RAO, although not frequent, is a limiting iatrogenic complication after transradial intervention (TRI) and precludes repeat use of the same radial artery for future procedures. Our technique involves obtaining access to the ipsilateral radial artery (RA) in the distal postocclusion segment and use of collateral channel between this segment and the interosseous artery (IOA) for advancing a guidewire and sheath in the IOA lumen and in brachial artery thereafter. © 2017 Wiley Periodicals, Inc.

New technique for treatment of postcatheterization radial artery pseudoaneurysm.

We report a new technique for treatment of radial artery pseudoaneurysm (RAP) caused by transradial access (TRA) for coronary angiography. Traditional extrinsic compression with radial flow cessation leads to a local milieu likely associated with an increase in probability of radial artery occlusion (RAO). Our technique involves obtaining ipsilateral radial artery access distal to the neck of the RAP followed by a prolonged sheath dwell time covering the neck of the RAP which allows the RAP sac to thrombose and maintains radial artery lumen patency. © 2016 The Authors. Catheterization and Cardiovascular Interventions Published by Wiley Periodicals, Inc.

Pseudoaneurysm of the Radial Artery on the Hand Secondary to Stabbing.

Pseudoaneurysm of the radial artery is extremely rare. It usually occurs secondary to trauma, interventional procedures, and infections. Symptoms occur due to mass effect by the pseudoaneurysm, digital ischemia, or nerve suppression. B-mode and color Doppler ultrasonography are the first choice in diagnosis. The pathognomonic ultrasound sign of pseudoaneurysm is the turbulent flow, which is called the "ying-yang" sign. Bandages, ultrasound probe compression, ultrasound-guided thrombin injection, covered stents, and surgical ligation can be used in treatment. In here, we present the case of a 28-year-old woman who developed a radial artery pseudoaneurysm after a stabbing injury in her hand and discuss the radiological and treatment options.

Radial Artery Pseudoaneurysm.

PURPOSE: To review the causes, clinical course, and management of patients with catheter-associated radial artery pseudoaneurysm (PSA). METHODS: We reviewed all patients diagnosed with radial artery PSA resulting from arterial line placement or radial artery access for cardiac procedures from 2010 to 2015. RESULTS: We identified 11 cases: 5 caused by arterial lines and 6 by cardiac procedures. The diagnosis was confirmed by duplex ultrasound in all cases; PSA size ranged from less than 1 cm to 5 cm in diameter. Spontaneous thrombosis (over a mean of 27 days) occurred in 4 patients; each PSA was smaller than 3 cm. Surgery was performed in 7 patients with excision of the stalk and repair of the artery as the most common procedure. Only one case was performed emergently for acute carpal tunnel syndrome. Complications occurring owing to either the PSA or the treatment were recorded in 5 patients. CONCLUSIONS: Spontaneous thrombosis may occur in smaller lesions over a few weeks. When required, surgery to evacuate the hematoma and repair the artery was effective in all cases. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Vascular Complications of Percutaneous Transradial Cardiac Catheterization.

The percutaneous transradial approach for coronary angiography and percutaneous coronary intervention is increasing in the United States. Although its vascular safety profile is better than the traditional femoral approach, it is important to learn about potential complications. In this article, we present two cases of vascular complications, namely, pseudoaneurysm and radial artery occlusion, after transradial cardiac catheterization, along with a review of the relevant literature.

Radial artery pseudoaneurysms after transradial cardiac catheterisation.

BACKGROUND: Although uncommon, radial artery access site complications are likely to become more frequent with the increased adoption of transradial cardiac catheterisation. There is a lack of data regarding the incidence and clinical features of radial artery pseudoaneuryms. We aimed to describe the incidence, clinical features and management of radial artery pseudoaneurysms in a high-volume transradial cardiac catheterisation centre. PATIENTS AND METHODS: We performed a search of the Vancouver Island Health Authority medical imaging database from 1st Jan 2008 to April 2012 looking for all radial and femoral artery pseudoaneuryms occurring after cardiac catheterisation. Hospital charts were reviewed to determine patient and procedural characteristics as well as management and outcome. RESULTS: There were a total of 14,968 coronary procedures performed over the four year search period, of which 13,216 (88%) were trans-radial. The incidence of radial artery pseudoaneurysm after cardiac catheterisation was 0.08%, and did not differ between transradial diagnostic angiography and PCI (0.07% vs 0.08%; P = 0.90). In contrast, the incidence of femoral artery pseudoaneurysm was higher, at 1.4% (P < 0.0001). Patients with radial pseudoaneurysms were generally elderly, with a median age of 77 years, and there were no gender differences. Only one patient had received a glycoprotein IIb/IIIa inhibitor, whilst two received warfarin post-procedure. The majority of cases (80%) were treated with surgical repair. CONCLUSIONS: We have demonstrated that radial artery pseudoaneuryms are a rare but important complication of transradial cardiac catheterisation, with patients generally requiring surgical repair. Most patients were elderly, but surprisingly only a minority were anti-coagulated with warfarin.

Radial artery avulsion--a rare complication of transradial catheterization.

Transradial access is becoming the default mode of catheterization in a growing number of centers in the United States. The increasing utilization of transradial access has led to significant reduction in access site complications especially bleeding complications. We report a rare complication of transradial catheterization of radial artery avulsion, which was successfully treated in an endovascular fashion during the index procedure. © 2014 Wiley Periodicals, Inc.

Comparison of safety of radial and femoral approaches for coronary catheterization in interventional cardiology.

BACKGROUND: The femoral approach has been the preferably used access in interventional cardiology as well for coronary diagnostics as for percutaneous coronary intervention, being perceived as easy and facilitating quick access with relatively low risk. Due to the results of the latest studies, however, the radial approach has become increasingly popular. The aim of this study was a safety analysis of cardiological interventional procedures (i.e., coronarography and PCI) according to the vessel approach. MATERIAL/METHODS: The 204 coronary interventions done in our Department of Interventional Cardiology were retrospectively analyzed. All the procedures were classified according to femoral or radial access. The incidence of local complications (e.g., major bleedings and hematomas) was assessed as well as the volume of contrast agent administered during the procedure and the radiation dose. RESULTS: It has been shown that radial approach, which is obviously more comfortable for patients, reduces the risk of local complications (0 vs. 2.97% and 0 vs. 3.96%) and does not lead to increased radiation exposure (p=0.88). However, there could be a larger volume of contrast agent administered (p=0.029), which in some cases could increase the risk of contrast-induced nephropathy. CONCLUSIONS: The radial approach should be recommended as a first choice because it is safer than the classical femoral approach, but one must be cautious in choosing radial approach patients with renal insufficiency.