APPLICATIONS OF VISCOELASTIC TESTING IN MICROSURGERY: A SYSTEMIC REVIEW AND META-ANALYSIS.

Viscoelastic testing including thromboelastography (TEG) and rotational thromboelastometry (ROTEM) has gained increasing popularity across many medical fields in recent years. As TEG/ROTEM testing uses whole blood sample and evaluates interactions between cellular components i.e., platelets, red blood cells and the clotting factors, these evaluations are uniquely capable of assessing coagulation in an in-vitro environment, resembling native conditions unlike those of conventual clotting tests (CCTs). While viscoelastic based protocols and applications are more commonplace in hepatic and cardiac surgery and trauma scenarios, results have attracted the attention of additional disciplines including microsurgery. TEG/ROTEM tests, with their ability to assess real-time risk of excessive bleeding or thrombosis, may be useful in the monitoring of microsurgery patients who may be at an increased risk for flap failure. The following review of TEG/ROTEM testing focuses on the most common applications of these coagulation tests and the evidence that does or does not support such uses. A systematic review and meta-analysis of the current application of TEG/ROTEM in microsurgery is reported along with an emphasis on the future that it might hold for the field.

Microvascular reconstruction of pediatric lower extremity trauma using free tissue transfer.

While free tissue transfer has long been established as a reliable microsurgical technique in the adult population, its application in pediatric reconstruction is a relatively recent phenomenon. Despite initial concerns regarding minute vessel diameters, increased propensity for vasospasm, and limited tissue availability, pediatric free tissue transfer is now a widely used technique that has demonstrated an acceptable level of donor and recipient site morbidity in children. Five flaps commonly used in the reconstruction of lower extremity trauma are discussed in this paper: the latissimus dorsi, rectus abdominis, anterolateral thigh, gracilis, and the subscapular and parascapular flaps. The indications, blood supply, advantages, and disadvantages of each are detailed. Incredible progress has been made in the application of microsurgical techniques to the pediatric population over the last several decades. With a healthy understanding of the anatomy and functionality of the donor site, the reconstructive surgeon can repair a variety of complex injuries with an acceptable morbidity and mortality rate.

Sequential inferior vena cava filter insertion and peripherally inserted central catheter placement through upper extremity veins.

PURPOSE: To report the sequential placement of inferior vena cava filter (IVCF) and peripherally inserted central catheter (PICC) using the same upper extremity venous access. MATERIAL AND METHODS: This is a retrospective study that reviewed the medical records of 379 consecutive patients who underwent IVCF insertion during a 39-month period at our center. Of these 379 patients, 28 patients had sequential insertion of an IVCF and a PICC through the same upper extremity venous access. The same vein entry site was used for placement of the IVCF followed by PICC insertion. Data collected included: indication and duration of IVCF and PICC placement, access site location, complications, and the type of IVCF. RESULTS: IVCFs were placed for prophylactic purposes in 15 patients (53.6%) and therapeutic purposes in 13 patients (46.4%). Right upper extremity veins were used for venous access in 27 patients (96.4%): brachial (n=16), basilic (n=9), and cephalic (n=2). The left basilic vein was used in one patient (3.6%). IVCFs were temporary in 20 patients (71.4%) and permanent in 8 patients (28.6%). There were no procedural complications. The OptEase filter was used in 23 patients (82.1%) and the TrapEase filter was used in 5 patients (17.9%). CONCLUSION: Simultaneous IVCF and PICC insertion using the same upper extremity venous access was feasible and safe in our series. This combined technique provides the patient with central venous access for repeated blood collections and intravenous therapy.

Intraoperative, imaging and pathological features in spinal cord vasculitis.

The surgical intraoperative findings in spinal cord vasculitis have not been previously described. The imaging appearances can mimic intramedullary spinal cord tumours. We present a patient with spinal cord vasculitis and mixed intraoperative findings of spinal vascular lesion and intramedullary tumour. Based on the absence of a confirmatory intraoperative smear, vessel obliteration and tumour debulking was avoided, preventing a catastrophic surgical complication. The limited literature and management options are also reviewed.

Rescue of an axillary-axillary arteriovenous graft not amenable to endovascular intervention by formation of an axillary loop: a case report.

Central venous obstruction associated with a distal arteriovenous fistula can result in massive swelling of the affected extremity and venous hypertension. We present the surgical rescue of an axillary-axillary arteriovenous access ((necklace graft) between the left axillary artery to the contralateral axillary vein), compromised by central venous stenosis, by conversion into an arteriovenous axillary loop graft (AVALG) as an additional 'exotic' grafting procedure in the anterior chest. This procedure resulted in the salvage of the patient's access and rapid resolution of the associated upper extremity swelling.

Impact of adequate dialysis before transplantation on development of chronic renal allograft dysfunction in 3-year posttransplant period.

INTRODUCTION: Transplantation is the preferred treatment modality for many patients with end-stage renal diseases. Despite all the efforts, allograft dysfunction remains the most important cause of graft loss. Finding new factors that improve graft survival is mandatory. METHODS: This prospective study included 93 patients transplanted between April 1999 and July 2000. The duration of dialysis prior to transplantation was analyzed with respect to the values before and up to 3 years posttransplantation, including blood urea nitrogen (BUN), creatinine, and blood pressure (BP) using 1-month intervals and triglyceride, cholesterol, low-density lipoprotein and high-density lipoprotein at 3-month intervals. In this study, graft dysfunction was defined as serum creatinine >1.8 mg/dL. Hypertension was defined as BP > 140/90 on two occasions or treatment with antihypertensive medications. Patients in the hypertensive group were divided into controlled versus uncontrolled hypertensives. RESULTS: The mean BUN and creatinine values of the patients prior to transplantation was 90 +/- 30 and 10.4 +/- 4, respectively. The patients had been on dialysis for an average of 4.7 years. Development of renal allograft dysfunction did not show any relationship to the duration of dialysis ptt. Patients with higher BUN and creatinine levels before transplantation experienced more episodes of renal allograft dysfunction in the 3-year posttransplant period (P < .05 for both BUN and creatinine). The relationship between BUN and creatinine prior to transplantation and risk of renal allograft dysfunction was more powerful among the group of uncontrolled hypertensives. CONCLUSION: Intensive dialysis prior to transplantation may exert positive effects on long-term graft function and survival.

Hematopoietic stem cell transplantation for beta-thalassemia major: experience in south of Iran.

INTRODUCTION: Allogeneic stem cell transplantation as a curative treatment for thalassemia major was established in Shiraz in 1993. In this article we describe our results of 10 years experience with allogeneic bone marrow transplantation for thalassemia major. METHODS: From June 1993 to January 2003, 112 cases of beta-thalassemia major underwent allogeneic marrow transplantation from HLA-identical or one antigen-mismatched related donors. Conditioning chemotherapy included busulfan (14 to 15 mg/kg), cyclophosphamide (200 mg/kg), and antithymocyte globulin (ATG; 40 mg/kg). Prophylaxis for graft-versus-host disease consisted of cyclosporine, prednisolone, and methotrexate. RESULTS: One hundred twelve patients with a diagnosis of beta-thalassemia major underwent allogeneic marrow transplantation during this period. The mean age of the patients was 9.5 years with the range of 2 to 20 years. The distribution of cases according to the Lucarelli classification were: 27 cases class I, 38 cases class II, and 47 cases class III. Eighty-seven of 112 patients (77.6%) with diagnosis of beta-thalassemia major are living with full engraftment at a median follow-up of 6 years (range 2 to 119 months). CONCLUSION: Allogeneic bone marrow transplantation has changed the outcome of disease dramatically. According to our results stem cell transplantation is the treatment of choice for class I and II (Lucarelli risk groups). Also, we recommend transplantation as a curative method for treatment of class III beta-thalassemic patients.