Post-cardiac arrest Sedation Promotes Electroencephalographic Slow-wave Activity and Improves Survival in a Mouse Model of Cardiac Arrest.

BACKGROUND: Patients resuscitated from cardiac arrest are routinely sedated during targeted temperature management, while the effects of sedation on cerebral physiology and outcomes after cardiac arrest remain to be determined. The authors hypothesized that sedation would improve survival and neurologic outcomes in mice after cardiac arrest. METHODS: Adult C57BL/6J mice of both sexes were subjected to potassium chloride-induced cardiac arrest and cardiopulmonary resuscitation. Starting at the return of spontaneous circulation or at 60 min after return of spontaneous circulation, mice received intravenous infusion of propofol at 40 mg · kg-1 · h-1, dexmedetomidine at 1 µg · kg-1 · h-1, or normal saline for 2 h. Body temperature was lowered and maintained at 33°C during sedation. Cerebral blood flow was measured for 4 h postresuscitation. Telemetric electroencephalogram (EEG) was recorded in freely moving mice from 3 days before up to 7 days after cardiac arrest. RESULTS: Sedation with propofol or dexmedetomidine starting at return of spontaneous circulation improved survival in hypothermia-treated mice (propofol [13 of 16, 81%] vs. no sedation [4 of 16, 25%], P = 0.008; dexmedetomidine [14 of 16, 88%] vs. no sedation [4 of 16, 25%], P = 0.002). Mice receiving no sedation exhibited cerebral hyperemia immediately after resuscitation and EEG power remained less than 30% of the baseline in the first 6 h postresuscitation. Administration of propofol or dexmedetomidine starting at return of spontaneous circulation attenuated cerebral hyperemia and increased EEG slow oscillation power during and early after sedation (40 to 80% of the baseline). In contrast, delayed sedation failed to improve outcomes, without attenuating cerebral hyperemia and inducing slow-wave activity. CONCLUSIONS: Early administration of sedation with propofol or dexmedetomidine improved survival and neurologic outcomes in mice resuscitated from cardiac arrest and treated with hypothermia. The beneficial effects of sedation were accompanied by attenuation of the cerebral hyperemic response and enhancement of electroencephalographic slow-wave activity.

Cavernous sinus dural arteriovenous fistula complicated by hippocampus venous congestion: A case report.

BACKGROUND: Hippocampal venous congestion is a rare complication associated with cavernous sinus dural arteriovenous fistulas (CS-DAVFs). CASE DESCRIPTION: A 74-year-old woman was admitted to the hospital with a swollen left eye. Isolated lesions were found in the left hippocampus and the middle cerebellar peduncle. Cerebral angiography revealed retrograde venous drainage of the bilateral inferior petrosal sinuses from the left CS-DAVF. The patient underwent transcatheter arterial embolization, resulting in complete resolution of the hippocampal lesions and neurological symptoms. CONCLUSION: Hippocampal injury is a rare complication of CS-DAVF. Attentive diagnosis and treatment can effectively prevent adverse consequences.

Early venous congestion after diep flap breast reconstruction: case report of a successful management.

BACKGROUND AND AIM: More than 250 000 women estimated to be diagnosed with breast cancer in the USA every year. Mastectomy is primary treatment for more than a third of those with early-stage disease. Most of the patients undergoing mastectomy receive breast reconstruction. A number of. Surgical techniques have been described to reconstruct the breast. With autologous tissue breast reconstruction, the plastic surgeon uses patient's own tissues, taken from a different part of the body where there is an excess of fat and skin. Deep inferior epigastric perforator (DIEP) flap is the autologous breast reconstruction technique of choice in our department due to long lasting results, low donor site morbidity and positive patient reported outcomes have been described.   Case Report: We present the case of a 42-year-old woman who underwent neoadjuvant chemotherapy followed by left breast simple mastectomy, axillary lymph-nodes dissection and later adjuvant radiation therapy (RT). After conclusion of RT a DIEP flap breast reconstruction was performed. Nine-hours after the operation, signs of acute venous congestion were noted. The venous congestion was treated by a combined surgical and medical approach based on pedicle discharge and ICU resuscitation protocol. After take back surgery, the patient was tightly monitored in the intensive care unit where intravenous heparin infusion and leech therapy were performed for 2 days. Flap congestion resolved completely, and the patient was discharged.   Conclusions: Venous congestion is very difficult to treat due to its potential multifactorial nature. The most important step is to recognize this kind of emergency because irreversible microvascular damages will develop in 6-8 hours. Because of multiple causes of venous congestion a timely multidisciplinary approach is mandatory, to maximize flap salvage and success rates.

Rim Enhancement after Technically Successful Transarterial Chemoembolization in Hepatocellular Carcinoma: A Potential Mimic of Incomplete Embolization or Reactive Hyperemia?

Contrast enhancement at the margins/rim of embolization areas in hepatocellular-carcinoma (HCC) lesions treated with transarterial chemoembolization (TACE) might be an early prognostic indicator for HCC recurrence. The aim of this study was to evaluate the predictive value of rim perfusion for TACE recurrence as determined by perfusion CT (PCT). A total of 52 patients (65.6 ± 9.3 years) underwent PCT directly before, immediately after (within 48 h) and at follow-up (95.3 ± 12.5 days) after TACE. Arterial-liver perfusion (ALP), portal-venous perfusion (PVP) and hepatic-perfusion index (HPI) were evaluated in normal liver parenchyma, and on the embolization rim as well as the tumor bed. A total of 42 lesions were successfully treated, and PCT measurements showed no residually vascularized tumor areas. Embolization was not entirely successful in 10 patients with remaining arterialized focal nodular areas (ALP 34.7 ± 10.1 vs. 4.4 ± 5.3 mL/100 mL/min, p < 0.0001). Perfusion values at the TACE rim were lower in responders compared to normal adjacent liver parenchyma and edges of incompletely embolized tumors (ALP liver 16.3 ± 10.1 mL/100 mL/min, rim responder 8.8 ± 8.7 mL/100 mL/min, rim non-responder 23.4 ± 8.6 mL/100 mL/min, p = 0.005). At follow-up, local tumor relapse was observed in 17/42, and 15/42 showed no recurrence (ALP 39.1 ± 10.1 mL/100 mL/min vs. 10.0 ± 7.4 mL/100 mL/min, p = 0.0008); four patients had de novo disseminated disease and six patients were lost in follow-up. Rim perfusion was lower compared to adjacent recurring HCC and not different between groups. HCC lesions showed no rim perfusion after TACE, neither immediately after nor at follow-up at three months, both for mid-term responders and mid-term relapsing HCCs, indicating that rim enhancement is not a sign of reactive hyperemia and not predictive of early HCC recurrence.

Effects of negative pressure wound therapy on an axial congested rabbit skin flap model without any bare surface.

One of the most important problems encountered in reconstructive surgery is partial or total flap loss, and venous congestion is the most common reason. It should be solved as early as possible. The purpose of this study is to investigate the effects of Negative pressure wound therapy (NPWT) on an ideal congested rabbit skin flap model without any open wound. The current study included 28 female, adult, New Zealand albino rabbits. Animals were divided into four groups according to the duration of NPWT to be applied. An axial pattern ideal congested skin flap was designed on the posterior surface of the ear. After surgical intervention on the right ears, we applied NPWT treatment for 2, 4, 6 and 8 days. The left ears were followed without any treatment. Samples were taken for edema, congestion and neo-angiogenesis examination. There was no significant difference between the NPWT applied group and control group in the 2nd, 4th, 6th, and 8th days for edema and neo-angiogenesis and no differences in the 2nd, 6th, and 8th days for congestion. NPWT group had a higher flap survival rate than the control group but without a significant difference. This study used an ideal congested rabbit skin flap model imitating venous congestion. Our findings illustrate that NPWT treatment does not have a significant effect on the congested skin flap model we utilized where a closed system was created maintaining a skin barrier without a bare surface of the flap. Level of Evidence: Level I, experimental study.

Bilateral Traumatic Carotid-Cavernous Fistula in a Child: Corkscrew Eyelid Vessels as an Indicator of Severe Congestion.

An 11-year-old girl presented with bilateral traumatic caroticocavernous fistula associated with corkscrew eyelid vessels, which were considered indicators of severe congestive disease in this case. Coil embolization was performed; similar to other congestive findings such as proptosis, orbital bruit, increased intraocular pressure, congested scleral and retinal vessels, engorged eyelid vessels resolved immediately after coil embolization. This pediatric case is unique given the caroticocavernous fistula was bilateral and was associated with prominent dilatation of the eyelid vessels, named for the first time as corkscrew eyelid vessels.

Digit Survival After Prolonged Digital Tourniquet Application Associated with Severe Venous Congestion: A Case Report.

CASE: A 22-year-old roofer presented to the emergency department with partial amputation of the left middle finger. He was treated with revision amputation using a glove tourniquet. He followed up 14 days later demonstrating a retained tourniquet with severe ischemic changes. The patient was managed conservatively with aspirin, smoking cessation, and observation. CONCLUSION: At 2-year follow-up, he had normal sensation and function and returned to work. A finger with severe, but incomplete arterial occlusion and profound venous congestion can be salvaged with conservative management of observation and anticoagulation with aspirin therapy after prolonged ischemia of 14 days.

Intra-abdominal pressure and its relationship with markers of congestion in patients admitted for acute decompensated heart failure.

Systemic congestion is one of the mechanisms involved in acute decompensated heart failure (ADHF). Increased intra-abdominal pressure (IAP), elicited by abdominal congestion, has been related to acute kidney injury and prognosis. Nonetheless, the link between diuretic response, surrogate markers of congestion and renal function remains poorly understood. We measured IAP in 43 patients from a non-interventional, exploratory, prospective, single center study carried out in patients admitted for ADHF. IAP was measured with a calibrated electronic manometer through a catheter inserted in the bladder. Normal IAP was defined as < 12 mmHg. At baseline, median IAP was 15 mmHg, with a reduction over the next 72 h to a median of 12 mmHg. A higher IAP at admission was associated with higher baseline blood urea (83 mg/dL [62-138] vs. 50 mg/dL [35-65]; p = 0.007) and creatinine (1.30 mg/dL vs. 0.95 mg/dL; p = 0.027), and with poorer diuretic response 72 h after admission, either measured by diuresis (14.4 mL/mg vs. 21.6 mL/mg; [p = 0.005]) or natriuresis (1.2 mEqNa/mg vs. 2.0 mEqNa/mg; [p = 0.008]). A higher incidence for 1-year all-cause mortality (45.0% vs. 16.7%; log-rank test = 0.041) was observed among those patients with IAP > 12 mmHg at 72 h. In patients with ADHF, higher IAP at admission is associated with poorer baseline renal function and impaired diuretic response. The persistence of IAP at 72 h above 12 mmHg associates to longer length of hospital stay and higher 1-year all-cause mortality.

Coronary vasomotor function and myocardial flow with bioresorbable vascular scaffolds or everolimus-eluting metallic stents: a randomised trial.

AIMS: The aim of this study was to compare the hyperaemic flow and vasomotor response to endothelium-dependent stimuli between bioresorbable vascular scaffolds (BVS) and metallic everolimus-eluting stents (EES) at 13 months. METHODS AND RESULTS: Seventy non-diabetic patients aiming to achieve complete revascularisation were randomised 1:1 to BVS or EES implantation. At 13 months, invasive coronary angiography was performed using intracoronary pressure and Doppler ultrasound measurements at rest and maximal hyperaemia. A vasomotor test to endothelium-dependent (acetylcholine) and independent (nitroglycerine) stimuli and optical coherence tomography (OCT) were also performed. Fifty-nine patients (30 BVS and 29 EES) underwent 13-month examination. Doppler ultrasound average peak velocity (49.0±17.5 vs 49.3±18.3 cm/sec; p=0.95), coronary blood flow (97.4±53.5 vs 88.3±46.7 ml/min; p=0.51), coronary flow reserve (2.6±0.9 vs 2.7±0.8; p=0.84) and fractional flow reserve (0.92±0.06 vs 0.94±0.04; p=0.17) were similar between the groups. The vasomotor test showed vasoconstriction response to acetylcholine in 75.6% proximal and 72.2% distal peri-scaffold segments without differences between study devices. BVS had larger in-scaffold vasoconstriction than EES (60.0% vs 27.6%; p=0.01) despite similar neointima response as assessed by OCT. CONCLUSIONS: BVS and EES had similar microcirculatory response to hyperaemia and predominant vasoconstrictive response in the peri-scaffold segments to endothelium-dependent stimuli. However, BVS exhibited larger vasoconstriction to endothelium-dependent stimuli in the scaffold segment.

White Sclera Painted Contact Lens for Masking of Conjunctival Neovascularization and Hyperemia Following Cosmetic Eye Whitening Procedure.

We describe a case of a 37-year-old veteran with recurrent conjunctival hyperemia 5 years after an eye-whitening conjunctivectomy procedure with mitomycin C who desired to have a repeat procedure by the original surgeon. Instead, the patient was counseled and successfully fitted with white sclera painted contact lenses to mask the regrowth of his conjunctival vasculature with excellent cosmetic results and comfort. Further eye-whitening surgery was, therefore, avoided. We conclude that hand-painted white sclera contact lenses with regular ocular surface health monitoring can be offered as a cosmetic, safer, and economical alternative to patients in order to avoid eye-whitening procedures known to induce ocular ischemia.

Endurance Exercise Intervention Is Beneficial to Kidney Function in a Rat Model of Isolated Abdominal Venous Congestion: a Pilot Study.

In this study, the effects of moderate intense endurance exercise on heart and kidney function and morphology were studied in a thoracic inferior vena cava constricted (IVCc) rat model of abdominal venous congestion. After IVC surgical constriction, eight sedentary male Sprague-Dawley IVCc rats (IVCc-SED) were compared to eight IVCc rats subjected to moderate intense endurance exercise (IVCc-MOD). Heart and kidney function was examined and renal functional reserve (RFR) was investigated by administering a high protein diet (HPD). After 12 weeks of exercise training, abdominal venous pressure, indices of body fat content, plasma cystatin C levels, and post-HPD urinary KIM-1 levels were all significantly lower in IVCc-MOD versus IVCc-SED rats (P < 0.05). RFR did not differ between both groups. The implementation of moderate intense endurance exercise in the IVCc model reduces abdominal venous pressure and is beneficial to kidney function.

THE USAGE OF RADIOFREQUENCY ABLATION FOR TREATMENT OF KELOIDS AND HYPERTROPHIC SCARS. / VYKORYSTANNIa RADIOChASTOTNOÏ ABLIaTsIÏ PRY LIKUVANNI KELOÏDNYKh TA GIPERTROFIChNYKh RUBTsIV.

OBJECTIVE: To evaluate the effectiveness of radiofrequency ablation (RFA) for scars tissue volume reduction, and influence on the clinical manifestations of keloid and hypertrophic scars. MATERIALS AND METHODS: Seventeen patients (9 males, 8 females), 19-62 years old, with some scars were enrolled into the prospective randomized controlled study: 10 with keloids, 7 with hypertrophic scars. Previous failed attempts to correct the scars were undertaken in 8 patients with keloids and in 3 patients with hypertrophic scars. The efficacy of four scar volume reduction methods was compared (12 scars in each group, 5 sessions at 10-day inter- vals): the first group - RFA, the second - intralesional 5-fluorouracil (5-FU) injections, the third - RFA followed by 5-FU injections and the fourth - RFA, injections of verapamil and then 5-FU. RESULTS: The scars volume reduction was faster after RFA (by 65.3 %) than after chemotherapy. Local verapamil application after RFA followed by 5-FU injections reduced scar volume after the fifth session by 78.3 %. Relieving of the associated symptoms and scars hyperaemia was faster after RFA than after cytostatic drug administration. Their simultaneous application, especially in combination with verapamil, intensified the effect. There were no infectious complications and haemorrhages. Ulcers 3-5 mm in diameter in the place of puncture on one scar in the first group, on two scars in the third and fourth groups were registered as the side effects. Seventeen scars in seven patients, who received RFA as a monotherapy or in combination with chemotherapy, were assessed 6 months after treatment. The average scars volume decreased from (3260.5 ± 2057.36) mm3 at the moment after the fifth session to (2110.6 ± 1296.16) mm3, p = 0.0033. CONCLUSIONS: Scars volume reduction was faster after five sessions of RFA than following local 5-FU injections. Combination of RFA with scars infiltration with verapamil and 5-FU strengthened the effect. In the same way, the above-mentioned methods influenced clinical symptomatology associated with the scars. Scars hyperaemia was also reduced by RFA. Radiofrequency ablation of excess scar tissue is advisable to use as an initial method for the treat- ment of keloids and hypertrophic scars, since it is easy to carry, is not expensive and effectively reduces the scar vol- ume, demonstrating the patient the opportunity to achieve a positive result.

Implementing local cooling to increase skin tolerance to ischemia during normal seating in people with spinal cord injury.

The purpose of this study was to investigate the effectiveness of local cooling in reducing reactive hyperemia after ischemia at the ischial tuberosities for people with spinal cord injury (SCI) during normal seating. The degree of the reactive hyperemic response is indicative of the extent of cellular stress caused by the ischemia. We hypothesized that reactive hyperemic skin blood flow (SBF) responses will be lower when local cooling is implemented by the wheelchair seat cushion. This study used a repeated measures design, and each subject underwent two conditions: normal seating with temperature control 'on' (cooling) and 'off' (non-cooling) for 30 min. Twenty-three participants with traumatic SCI were recruited. SBF and skin temperature were collected before, during and after seating. SBF signals were processed with short-time Fourier analyses to examine the underlying vascular control mechanisms, including the following (corresponding frequency bands): metabolic (0.0095-0.02 Hz), neurogenic (0.02-0.05 Hz), and myogenic (0.05-0.15 Hz) spectral densities. Our results showed that with cooling, skin temperature decreased (range -0.4 ~ -3.1 °C, p = 0.002), and reactive hyperemia parameters (normalized peak SBF and perfusion area) were reduced (p = 0.02, p = 0.033, respectively). In addition, changes in normalized peak SBF (non-cooling - cooling) was moderately correlated with changes in normalized metabolic and neurogenic spectral densities. Our findings suggested that local cooling has a positive effect on reducing the cellular stress caused by ischemia during normal seating. Metabolic and neurogenic SBF control mechanisms may play a minor role. Further exploration of the effect of temperature control on pressure injury prevention is warranted.

[Varicoceles, pelvic varices and pelvic congestion syndrome: Interventional radiology in diagnosis and treatment]. / Varicocèles, varices pelviennes et syndrome de congestion pelvienne : place de la radiologie interventionnelle.

Genital venous insufficiency in men is usually of constitutional origin due to valvular incontinence. Genital venous insufficiency in female is more often generated by major, lasting, and possibly repeated pregnancy-related hyperpressure phenomena. Genital venous insufficiency in men is usually expressed by visible and recognizable peritesticular varicocele. Of simple anatomic structure, it is easily accessible to endovascular treatment by embolization, which is the first-line therapy nowadays. Genital venous insufficiency in women results in a pelvic predominant varicosis, which should be evoked in case of chronic pelvic pain or atypical venous afferents to the lower limbs. Precise and guided interrogation and clinical examination allow the attending physician to be the first actor in the detection of symptomatic pelvis venous insufficiency in men and women. A chronic pelvic pain in female should evoke a pelvic congestion syndrome, symptomatic translation of pelvic varicosis, especially if it increases at the end of the day, at the effort, in pre-menstrual period. Treatment with endovascular embolization is the only therapeutic option for female pelvic venous insufficiency, of complex architecture and deep anatomical situation. The interventional radiologist offers a complete, minimally invasive and efficient treatment with limited hospital costs and perioperative constraints.

Pediatric Replantation and Revascularization.

Replantation and revascularization in the pediatric extremity has unique challenges that provide a fertile field of research and clinical experience. Children regenerate peripheral nerves rapidly, resulting in good sensory and motor function. They adapt well to functional deficits and mismatch errors of reinnervation. The technical aspects of microsurgical care in children can be challenging because the structures are small. Additional technical challenges include preservation of growth centers, prevention of vasospasm, protection of the reconstruction, and psychosocial care. Despite these challenges, children show excellent functional outcomes with minimal complications.