Detection of wound healing disorders after major amputations by measurements of the microcirculation: A prospective single-center study.

Introduction: Although major amputations can often be avoided due to evolving methods of endovascular and surgical revascularizations techniques, in patients with chronic limb-threatening ischemia, it is still necessary in some cases. Aim of this study was the detection of wound healing disorders through intraoperative microcirculation measurements in major limb amputations. Materials and methods: In this single-center clinical study, patients with an indication for major amputation were enrolled prospectively. Cause of amputation, patients' comorbidities including cardiovascular risk profile were assessed. Macrocirculation, as well as microcirculation were assessed. Microcirculation measurements were performed by fluorescence angiography with the administration of indocyanine green. A preoperative measurement was obtained at the amputation level, followed by three additional measurements of the amputation stump postoperatively. Wound healing was monitored and correlated with the microcirculatory findings, based on the perfusion parameters ingress and ingress rate, calculated in the indocyanine green fluorescence video sequences of the amputation stumps. Results: Forty-five patients were enrolled, including 19 (42%) below-the-knee amputations and 26 (58%) above-the-knee amputations. When considering the need for revision, a change in the microperfusion parameters was observed postoperatively. The mean value for ingress was significantly lower directly postoperatively in stumps requiring revisions (5 ± 0 A.U. versus 40.5 ± 42.5 A.U., p < 0.001). The mean value of ingress rate behaved similarly (0.15 ± 0.07 A.U./s versus 2.8 ± 5.0 A.U./s, p = 0.005). The evaluation of indocyanine green measurements when wound healing disorders occurred also showed nonsignificant differences in the mean values. Conclusion: Fluorescence angiography after major lower limb amputations appears to be an option of depicting microperfusion. Especially, the early postoperative detection of reduced perfusion can indicate a subsequent need for revision. Therefore, this method could possibly serve as a tool for intraoperative quality control after major limb amputation.

Independent Factors Influencing Changes in Baroreceptor Sensitivity after Carotid Endarterectomy.

BACKGROUND: Carotid endarterectomy (CEA) is a well-established standard therapy for patients with symptomatic or asymptomatic high-grade carotid stenosis. The aim of carotid endarterectomy is to decrease the risk of stroke and avoid relevant functional loss. However, carotid endarterectomy is known to be associated with hemodynamic dysregulation. In this study we compared eversion CEA (E-CEA) and conventional CEA (C-CEA) regarding postoperative blood pressure values as well as preoperative and postoperative baroreceptor sensitivity in the first 7 days after surgery. The aim was to find possible factors influencing changes in baroreceptor sensitivity. METHODS: Patients (111 patients were enrolled, of which 50 patients received C-CEA and 61 patients E-CEA) were prospectively enrolled in this study. For the measurement of baroreceptor sensitivity, a noninvasive Finometer measuring device from Finapres Medical System B.V. (Amsterdam, The Netherlands) was used. Measurements were performed 1 day before surgery (PRE), directly after surgery (F1), on day 1 (F2), day 2 (F3), and on day 7 (F4) postoperatively. RESULTS: Postoperative blood pressure values were significantly higher in the E-CEA group on the day of surgery (F1) (P < 0.001) and on day 1 (F2) (P < 0.001). From day 2 (F3, F4) postoperatively, no significant difference was found between the 2 groups. The invasive blood pressure measurement in the postoperative recovery room showed significantly higher systolic blood pressure values in the E-CEA group (P = 0.001). The need of acute antihypertensive therapy was significantly higher in the recovery room in the E-CEA group (P = 0.020). With regard to changes in baroreceptor sensitivity, significantly lower baroreceptor sensitivity (BRS) values were recorded in the E-CEA group at 1 day (F2) postoperatively (P = 0.005). The regression analysis showed that the applied surgical technique and the patient's age were significant factors influencing changes in baroreceptor sensitivity. CONCLUSIONS: In this study we could confirm higher blood pressure levels after E-CEA in the first 2 days after surgery. Additionally, we identified 22 factors possibly influencing baroreceptor sensitivity: surgical technique and age. Based on the data obtained in this study, hemodynamic dysregulation after CEA (E-CEA, C-CEA) is temporary and short-term. Already after the second postoperative day, there was no significant difference between the E-CEA and E-CEA groups, this effect remained stable after 7 days.

Teachability of multispectral optoacoustic tomography.

To date, the appropriate training required for the reproducible operation of multispectral optoacoustic tomography (MSOT) is poorly discussed. Therefore, the aim of this study was to assess the teachability of MSOT imaging. Five operators (two experienced and three inexperienced) performed repositioning imaging experiments. The inexperienced received the following introductions: personal supervision, video meeting, or printed introduction. The task was to image the exact same position on the calf muscle for seven times on five volunteers in two rounds of investigations. In the first session, operators used ultrasound guidance during measurements while using only photoacoustic data in the second session. The performance comparison was carried out with full-reference image quality measures to quantitatively assess the difference between repeated scans. The study demonstrates that given a personal supervision and hybrid ultrasound real-time imaging in MSOT measurements, inexperienced operators are able to achieve the same level as experienced operators in terms of repositioning accuracy.

Management of vesicoenteric fistulas arising from perforated Meckel's diverticulum: a report of a case and review of the literature.

Vesicoenteric fistulas are rare, with an incidence of 0.1%-0.2% in the general population, and Meckel's diverticulum is a rare cause, accounting for less than 5% of cases with challenging diagnosis due to atypical symptoms at the admission. This article presents a case of a vesicoenteric fistula formation between Meckel's diverticulum perforated by a foreign body and urinary bladder in a 38-years-old Caucasian male admitted to emergency department due to colicky abdominal pain located in the lower abdomen. An extensive review of the literature was conducted referring all the cases of vesicoenteric fistula incorporating Meckel's diverticulum to elucidate the clinical characteristics, explore the diagnostic yield, and to summarize the therapeutic approach.

Ectopic kidney injury due to blunt abdominal trauma.

Ectopic kidney is a relatively uncommon anatomic variation that is usually detected incidentally in patients undergoing imaging for an unrelated reason. Most cases are asymptomatic and are often revealed by a complication; however, ectopic kidney is generally associated with higher risk of traumatic injury, urinary tract infection, renal calculi and other urologic conditions. We report the case of a 65-year-old male patient with a post-traumatic renal laceration on a previously undiagnosed ectopic pelvic kidney, with successful conservative treatment.

Endovascular Retrieval of a Detached and Dislocated Venous Port Catheter in the Right Heart Chamber Using a Triple-Loop Snare Device.

The authors present a case of a successful percutaneous retrieval of a detached port-a-catheter device that had migrated to the right cardiac chambers in a patient with inoperable pancreatic cancer and hepatic metastases. The patient was admitted to the vascular clinic department on an urgent basis due to an accidental detachment of the catheter during removal at another hospital. The catheter had migrated from the initial placement site in the right subclavian vein to the superior vena cava and right heart chambers. Under local anesthesia, the right femoral vein was accessed using the Seldinger technique, and the migrated catheter was retrieved using a triple-snare-loop device for foreign body removal. Chest radiography after the retrieval procedure did not show any foreign bodies in the right heart chambers or superior vena cava. The patient was discharged home the following day.

Anterior Tibial to Dorsalis Pedis Bypass to Manage Acute Ischemia Attributed to Pilon Fracture.

Pilon fractures of the distal tibia are usually the result of a high-energy trauma and can affect seriously the arterial vasculature carrying an increased risk of amputation at the malleolar level or higher. Such cases represent a challenge for the orthopedic surgeons and a multidisciplinary approach is mandatory in order to salvage the threatened limb. We present an unusual case of a closed pilon fracture with injury of all tibial vessels leading to acute limb threatening ischemia. The patient was treated successfully with external fixation and a short tibial-pedal bypass with use of an autologous reversed saphenous vein graft. This example dictates how a distal leg fracture can be dramatic and that awareness of vascular examination coupled with high suspicion of vascular damage can be limb-saving. Multidisciplinary approach is warranted since the topology and complexity of the ankle lesions necessitate staged orthopedic reconstructions with tibio-distal bypass and appropriate skin coverage of the distal anastomosis.

Surgical Reconstruction of Traumatic Pseudoaneurysm of Palmar Arch Caused by Blunt Trauma.

Although rare, pseudoaneurysms (PAs) of the palmar arch are mostly considered benign. However, they can cause severe complications if left untreated or misdiagnosed. There are a few data on traumatic PAs of the palmar arch, particularly those most commonly caused by penetrating hand injuries. However, PAs caused by blunt trauma are more insidious in onset, presenting as a painful pulsatile mass in the palmar area of the hand, and require prompt diagnosis and management to avoid catastrophic sequelae. Our case is the first study to describe a patient with traumatic PA of the palmar arch caused by blunt trauma that was treated with surgical reconstruction and venous bypass interposition.

Solitary abdominal wall hydatid cyst-a rare condition.

Hydatid disease is a parasitic infection by a tapeworm of the genus Echinococcus that usually presents in the liver and lungs. Presentation of the disease as a solitary abdominal wall lesion, however, is a rare entity and only nine cases have been reported in the literature thus far. We present the case of a 53-year-old Caucasian female presenting with a mass located in the left flank that was proven to be a solitary hydatid cyst intraoperatively.

Evisceration of a Small Bowel Segment Through a Drain Site: Lesson Learnt.

Evisceration is described as the removal of intra-abdominal organs outside the abdominal cavity after partial or complete dehiscence of an operative incision. Multiple organs have been reported in the literature as being eviscerated through a drain site. Zero point five per cent (0.5) to 1.2% of all cases include the small bowel. In most cases, evisceration occurs three to eight hours post-operation. This article reports a case of an eviscerated small bowel segment through a drain site, along with the drain six hours post-operative. To our knowledge, such a complication following open abdominal or laparoscopic surgery has not yet been reported. Due to the imminent risk of strangulation and subsequent necrosis of the eviscerated visceral organ, drain site evisceration requires immediate intervention.

Asymptomatic Spontaneous Migration of the Tip of Port-A-Cath System Into the Right Internal Jugular Vein: A Case Report of an Uncommon Complication.

Venous port catheters are devices that allow access to the central venous system and, in clinical practice, are used for patients who require long-term intravenous therapy. The ideal position of the catheter tip is the distal superior vena cava and can be confirmed by a postoperative chest X-ray. Complications during and after the implantation are not rare, but spontaneous migration of the catheter tip into the internal jugular vein is an uncommon complication. Catheter migration may be accompanied by neck, shoulder, and ear pain. Venous phlebitis and thrombosis, and neurological complications, can become potentially life-threatening. We report a case of a spontaneous catheter tip migration into the right internal jugular vein that was diagnosed in a random chest roentgenography. The patient was taken to the operative room, and the catheter was successfully removed.

Hand compartment syndrome due to extravasation of contrast medium. A technical error. A report of a case and review of the literature.

The extravasation of contrast agents is one of the most common and remarkable complications during a computed tomography (CT) scan. The clinical manifestations are commonly minimal, leading to mild symptoms. However, in rare cases of high-volume extravasation, the complications are extremely threatening. Compartment syndrome of the hand and the forearm leads to critical dysfunction and upper limb necrosis. This article reported an unusual case of hand compartment syndrome following extravasation of iodinated contrast agent from a peripheral venous catheter, during a CT angiography, and its surgical treatment. Moreover, a literature review regarding all published similar surgically treated cases was conducted.

Update on the TREO endograft device: overview of its safety and efficacy.

INTRODUCTION: The TREO abdominal aortic stent graft system (Terumo Aortic, Sunrise, Fla) is a low-profile, trimodular endovascular endoprosthesis for the endovascular repair of abdominal aortic aneurysm (AAA). The objective of the present study was to collect and discuss all the available modern data of this device highlighting especially its mid-and long-term clinical results. AREAS COVERED: This updated review article presents the most current results from great-scale clinical studies and the RATIONALE registry involving also angulated neck anatomies and challenging AAA geometries, reflecting the real-world experience. EXPERT OPINION: The global, multicenter RATIONALE registry prospectively enrolled 202 patients (mean age 73.0 ± 7.8 years) who underwent EVAR. Technical success, primary clinical success and assisted primary patency rate was 96%, 92.2% and 97%, respectively. The clinical success at 1 year was 96%. Another multicenter, non-randomized, clinical trial confirmed also high technical and clinical success. Additionally, a comparative study comparing favorable and hostile necks in AAA, demonstrated a comparable technical success (95.2%), achieving proper sealing and technical success in the hostile neck group. TREO endograft seems to be safe and effective for EVAR, especially in hostile neck anatomies. Long-term outcomes from ongoing registries are awaited to complete these results.

Safety and Efficacy of Intentional Celiac Artery Coverage in Endovascular Management of Thoracoabdominal Aortic Diseases: A Systematic Review and Meta-analysis.

PURPOSE: Thoracic endovascular aortic aneurysm repair (TEVAR) has emerged as an attractive alternative option in the treatment of thoracoabdominal aortic aneurysm (TAAA) diseases, reporting lower morbidity and mortality rates compared with open or hybrid repair. A challenging situation arises when the aneurysm involves the celiac artery (CA), precluding a safe distal landing zone. We investigated the safety and efficacy of CA coverage in the treatment of complex TAAA diseases during endovascular management. MATERIALS AND METHODS: A review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. The electronic bibliographic sources searched were MEDLINE and SCOPUS databases. Primary outcomes of interest were perioperative and 30-day mortality. Any type of endoleak, mesenteric ischemia, perioperative spinal cord ischemia, and reintervention rates were secondary end points. A random-effects meta-analysis was performed. Summary statistics of event risks were expressed as proportions and 95% confidence interval (CI). RESULTS: Ten observational cohort studies published between 2009 and 2020, reporting a total of 175 patients, were eligible for quantitative synthesis. Indications for TEVAR were primary TAAAs in 82% of patients, aortic dissection in 14% of patients, type Ib endoleak after previous endograft deployment in 3% of patients, and penetrating aortic ulcer in 1 patient. Reintervention rate was 9% (95% CI, 4%-20%) and spinal cord ischemia was 7% (95% CI, 4%--12%). Type II endoleak was the predominant type of endoleak in 10% of patients (95% CI, 4%-22%), followed by type I endoleak in 5% of patients (95% CI, 2%-12%) and type III endoleak in 1% (95% CI, 0%-16%) of patients. Mesenteric ischemia occurred in 6% of patients (95% CI, 3%-10%). Thirty-day mortality was 5% (95% CI, 2%-13%) and the pooled estimate for overall mortality was 21% (95% CI, 14%-31%). CONCLUSIONS: Celiac artery coverage during TEVAR is a challenging but feasible option for the treatment of TAAA diseases, providing acceptable morbidity and mortality rates. Demonstration of adequate visceral collateral pathways before definitive CA coverage is the sine quo non for the success of the technique.

Unmasking the Coronary-Subclavian Steal Syndrome: The Culprit Lies in the Subclavian Artery. A Report of a Case and Review of the Literature.

The coronary-subclavian steal syndrome is a hemodynamic phenomenon in which a subclavian artery stenosis or occlusion impairs blood flow at the origin of the left internal mammary artery used for coronary artery bypass grafting (CABG), causing retrograde blood flow and thus provoking symptoms of cardiac ischemia and its complications. Once considered the gold-standard operation of choice, open revascularization has now been abandoned as a first line treatment and replaced by endovascular techniques. In all cases, detailed and oriented physical examination in combination with further imaging in high clinical suspicion for coronary-subclavian steal syndrome remains the sine qua non of the preoperative examination of the patient. We report the case of a 50-year-old male patient suffering from acute onset angina post- coronary artery bypass grafting and managed by endovascular means.

An update on the ovation abdominal stent graft for the treatment of abdominal aortic aneurysms: current evidence and future perspectives.

Introduction: The Ovation stent-graft has presented satisfactory mid-term results in the management of abdominal aortic aneurysms (AAA). Its unique design with uncoupling of fixation and sealing and the lowest profile in the market has expanded the treatment in AAA with challenging neck anatomies and, especially, in the females presenting mostly with narrow iliac access vessels. Morever, a new design modification, the Ovation Alto was recently introduced in the Market, while certain off-label uses of the Ovation in treating either juxtarenal- or short-necked AAA have been proposed. Areas covered: Aim of this article was to present the current articles with the long-term results of the Ovation endograft and discuss the new developments and modifications in its use. Expert commentary: the Ovation stent-graft exhibits very satisfactory clinical long-term results in AAA treated within the instructions-for-use, expands significantly the treatment of AAA in females and overcomes reliably challenging anatomical issues of the infrarenal neck that would render these cases ineligible for treatment with any other endograft. Εxperience with the specific, unique technical features of Ovation as well as careful selection of patients and meticulous preoperative study of the AAA anatomy are key-elements to the successful performance of this endograft.

Composite Contralateral Axillobifemoral Bypass for Ipsilateral Axillobifemoral Bypass Infection.

We report an innovative technique in an 82-year-old patient with a patent but infected right axillobifemoral (AxBF) bypass performed 7 years ago owingto critical limb ischemia who underwent a semielective de novo left-sided composite AxBF bypass consisting of a central prosthetic polytetrafluoroethylene segment and distal autologous limbs to the femoral regions (femoral crossover bypass vein to the right limb using the femoral vein and jump graft to the left femoral limb using the great saphenous vein.) Although AxBF bypass is not considered the "gold standard" surgical composite revascularization procedure in the suprainguinal region, it can constitute an acceptable intervention in selected cases.

Τhe AFX unibody bifurcated unibody aortic endograft for the treatment of abdominal aortic aneurysms: current evidence and future perspectives.

Introduction: AFX is a bifurcated unibody aortic endograft for the treatment of Abdominal Aortic aneurysms. It consists of an inner metallic endoskeleton with multiple metallic struts covered by a polytetrafluoroethylene graft fabric. The endoskeleton is sutured to the outer fabric only at the proximal and distal ends. The unique design of AFX aims at fixation onto the aortic bifurcation while a proximal cuff ensures sealing at the infrarenal level.Areas covered: Since this endograft design by Endologix has undergone significant changes over the last years, the aim of this article is to present its unique structure and deployment method and discuss the relevant clinical results as well as reported complications and associated concerns.Expert commentary: the AFX stent-graft exhibits very satisfactory clinical mid-term results in abdominal aortic aneurysms treated within the instructions-for-use. Its 'active-seal' concept of infrarenal fixation stemming from the loose conjugation of the fabric material to the endoskeleton can accommodate efficiently to challenging necks with thrombus or morphological irregularities, thereby extending the anatomical sealing zone without exerting significant radial outward force. Long-term results are needed to validate the promising performance of AFX.