Popliteal Artery Entrapment Syndrome in Children: Experience With Four Cases of Acute Ischaemia and Review of the Literature.

OBJECTIVE: Popliteal artery entrapment syndrome (PAES) is an uncommon anatomical anomaly, frequently described in adults. The most common symptom is claudication. Acute limb ischaemia (ALI) in children is rare, but it may evolve and lead to limb loss or lifelong complications. Clinical and surgical experience of PAES in children is reported. Data from the literature are analysed in order to assess the severity of this disease and to identify the factors characterising the diagnosis and the outcome of treatment in paediatric patients. METHODS: Four children (aged 7-16 years) were referred with ALI due to PAES. Among the 439 articles reporting cases of PAES, 55 patients under 18 years of age were the focus. The PAES cases were classified according to the Love and Whelan classification modified by Rich. RESULTS: Data from 79 children (106 limbs, 27 bilateral PAES) were collected and analysed. Type I PAES was present in 41 (39%), Type II in 23 (22%), Type III in 24 (23%), Type IV in 12 (11%), and Type V in two (2%) limbs. A functional PAES was present in one patient bilaterally. In two cases, the type of PAES was not reported. Claudication occurred in 68 cases (64%), and ALI in 19 (18%). In 60 cases (57%), revascularisation with or without myotomy was required; myotomy alone was performed in 41 cases (39%). CONCLUSIONS: Symptomatic PAES in children should be considered a severe condition requiring urgent investigation in order to avoid any delays in the treatment. Early diagnosis and treatment are essential to prevent serious complications. The long-term outcomes of surgical treatment with the correction of the anatomical anomaly and vascular reconstruction are satisfactory with a low complication rate.

Amplatzer Plug to Occlude the Internal Iliac Artery During Endovascular Aortic Aneurysm Repair: A Large Multicenter Study.

OBJECTIVE: During endovascular repair of abdominal aortic aneurysms (EVAR), in the absence of a distal iliac landing zone, the Amplatzer plug is increasingly being used to replace other internal iliac artery (IIA) embolization techniques. This study aimed at assessing the technical success, complication occurrence, and durability of the Amplatzer plug for IIA embolization. METHOD: From January 1, 2007 to December 31, 2013, all consecutive patients who underwent internal iliac embolization with an Amplatzer plug during EVAR were included in the study. There were 169 patients, (160 men, 9 women, mean 75 ± 9 years), treated by unilateral (158 cases, 93%) or bilateral (11 cases, 7%) embolization of the IIA, performed either separately prior to (65 cases, 38.5%) or during EVAR (104 cases, 61.5%). Follow up CT scan and/or US scan were performed 1 month after treatment and yearly thereafter. The inclusions were done retrospectively but the series was continuous and consecutive. Data were collected and analyzed using acquisition REDCap software. RESULTS: The technical success rate was 97.6%. Failures were device migration (n = 1), navigation failure (n = 2), and release outside the target zone (n = 1). On average, 1.43 plugs were required to achieve the embolization. The average amount of contrast agent for the embolization procedure was 111 ± 51 mL and the radiation dose was 127,777 ± 89,528 mGy/cm(2). The total fluoroscopy time was 854 ± 538 seconds. No re-canalization of the IIA trunk was observed during follow up. Complications were buttock claudication (n = 41, 24.3%), which resolved in 24 cases (58.5%, 24/41) at the first follow up, and intestinal ischemia requiring limited bowel resection in two cases. CONCLUSION: This multicenter study is the largest published to date. It demonstrates the efficacy and reliability of the Amplatzer plug to embolize the IIA during EVAR, with few side effects.

Early Experience of Endovascular Repair of Post-dissection Aneurysms Involving the Thoraco-abdominal Aorta and the Arch.

OBJECTIVES: Outcomes are reported in management of post-dissection aneurysms involving the aortic arch and/or thoraco-abdominal segment (TAAA) treated with fenestrated and branched (complex) endografts. METHODS: This report includes all patients with chronic post-dissection aneurysms >55 mm in diameter, deemed unfit for open surgery, treated using complex endografts between October 2011 and March 2015. When appropriate, staged management strategies including left subclavian artery revascularization, thoracic endografting, dissection flap fenestration or tear enlargement, and other endovascular procedures were performed at least 3 weeks prior to definitive complex endovascular repair. The following outcome data were collected prospectively at discharge, 12 months and annually thereafter: technical success, endoleaks, target vessel patency, false lumen patency, aneurysm diameter, major and minor complications, re-interventions, and mortality. RESULTS: The cohort comprised 23 patients with a median age of 65 years. Staged procedures were performed in 14 patients (61%). Seven patients with dissections involving the arch were treated with inner branched endografts, and 16 TAAA patients were treated with fenestrated or branched endografts. The technical success rate was 71% following arch repair and 100% following TAAA repair. During early follow up, one of the arch group patients died and one in the TAAA group suffered spinal cord ischemia. The median follow up was 12 months (range 3-48), during which time one patient died of causes unrelated to aneurysm or treatment. Two early re-interventions were performed in the arch group to correct access vessel complications and there were a further two late re-interventions in the TAAA group to treat endoleaks. All target vessels (n = 72) remained patent. CONCLUSIONS: This experience indicates that complex endovascular repair of post-dissection aneurysms is a viable alternative to open repair in patients deemed unfit for open surgery. There are insufficient data to allow comparison with the outcome of open surgery in anatomically similar, but fit, patients.

[Traumatic injuries of the descending thoracic aorta apart from the isthmus: diagnosis and therapeutic approach]. / Les lésions traumatiques de l'aorte descendante en dehors de l'isthme: particularités diagnostiques et thérapeutiques.

Lesions involving the descending thoracic aorta apart from isthmus are rare and less known by anesthetists. We report the clinical course of two severely injured patients who sustained a thoracic aortic rupture in whom favorable outcome was achieved with endovascular treatment. Mechanisms, diagnosis and therapeutics aspects of these rare lesions are discussed according to literature.

Superior sagittal sinus reconstruction using a femoral venous graft after total removal of a meningioma. Case report.

OBJECTIVE: Resection of a parasagittal meningioma invading the superior sagittal sinus (SSS) needs the reconstruction of the sinus by a patch or a venous graft depending of sinus invasion degree. METHOD: We present here a case of a 21-year-old man who underwent radical removal of a radio-induced parasagittal meningioma totally invading the posterior third of the sinus. For its reconstruction, we used the patient's left superficial femoral vein without valves as an autograft, by realizing two end-to-end anastomoses between the sinus and the graft after an en-bloc removal of the meningioma and the invaded sinus. RESULTS: Two years after surgery, clinical examination of the patient was strictly normal and the femoral venous graft was still patent on CT angiograms. CONCLUSION: The superficial femoral vein without valves seems to be convenient for SSS reconstruction.

Anterior minimally invasive extrapleural retroperitoneal approach to the thoraco-lumbar junction of the spine.

BACKGROUND: The anterior approach to the thoraco-lumbar junction of the spine allows therapeutic interventions on post-traumatic, infectious, and neoplastic vertebral lesions from T11 to L2 combining spinal cord decompression, corporectomy, and vertebral body fusion. However, this approach also has a reputation for damaging the intervening anatomic structures (lungs, peritoneum, and diaphragm). The objective of this study was to show that both nervous structure decompression and anterior vertebral reconstruction can be achieved via an anterior minimally invasive extrapleural retroperitoneal (AMIER) approach. MATERIAL: We describe each of the steps of the AMIER approach to the thoraco-lumbar junction of the spine. RESULTS: The AMIER approach ensures excellent exposure that allows full decompression and satisfactory anterior anatomic reconstruction. The main difficulties and complications relate to the lungs, and a painstaking and rigorous technique limits the complications compared to conventional thoraco-phreno-lumbotomy.

[Minimally invasive extrapleural retroperitoneal approach for thoracolumbar junction. Prospective study of 40cases]. / Abord mini-invasif de la charnière thoracolombaire du rachis par voie extrapleurale, rétropéritonéale. Étude prospective sur 40cas.

STUDY DESIGN: Prospective study. BACKGROUND AND PURPOSE: The anterior spinal cord decompression and spinal interbody fusion is considered an effective therapeutic procedure for thoracolumbar spine junction (TLSJ) (T11 to L2) fractures and tumors. However, it is also known to be associated with considerable surgery-related trauma. The purpose of this study was to show that neural elements decompression and anterior reconstruction at the TLSJ can be performed via a minimally invasive extrapleural retroperitonal approach (MIERA). METHODS: The authors studied prospectively the hospital records and radiological data obtained in 40 patients (mean age: 43.6 years, range: 16-74 years) who all underwent first a posterior fixation followed by a thoracic (T11 or T12) or lumbar (L1 or L2) corpectomy and spinal fusion via a MIERA. RESULTS: The MIERA provided excellent exposure to facilitate complete decompression and anterior reconstruction in all patients, as verified on follow-up radiographic studies. More than 2years follow-up record is available for 24 patients, a one year follow-up record for 14 others, and six months follow-up for the last two ones. Radiography demonstrated anatomically correct reconstruction in all patients, as well as a solid fusion or a stable compound union in the 24patients for whom a minimum of 2years follow-up records was available. CONCLUSIONS: The MIERA allows the surgeon to perform anterior thoracolumbar spine surgery via a less invasive approach. The authors demonstrate the efficacy and safety of this technique and its potential to reduce perioperative morbidity compared with conventional retroperitoneal lumbar spine surgery or thoracophrenolombotomy.

[Long-term patency of a popliteal venous aneurysm treated surgically]. / Perméabilité à long terme d'un anévrisme veineux poplité traité chirurgicalement.

Popliteal venous aneurysms are infrequent but should be screened for with venous ultrasound in patients with acute or chronic venous diseases because of the unpredictable high risk of thromboembolism and potential curability. Therapeutic alternatives are discussed: follow-up, anticoagulation, surgery with different techniques. To illustrate this, we report the case of a 51-year-old woman presenting pulmonary embolism and left popliteal venous aneurysm treated surgically. Anticoagulation was stopped 12 months after surgery and primary patency was maintained 40 months after surgery. In patients with thromboembolism disease, clinicians should search for popliteal venous aneurysms in order to prevent recurrent thrombosis and adapt follow-up and treatment.

Early carotid endarterectomy after intravenous thrombolysis for acute ischaemic stroke.

UNLABELLED: After intravenous thrombolysis (IVT) for acute ischaemic stroke (AIS), a severe cervical internal carotid artery (ICA) stenosis may remain and increase the risk of recurrent stroke. Carotid endarterectomy (CEA) has been shown to be effective in reducing the risk of stroke. However, it is not well known whether CEA can be performed safely after thrombolysis, and, if so, when. We report a prospective study of CEA for residual high-grade cervical ICA stenosis performed within 15 days after IVT for AIS. METHODS: All the patients had a brain magnetic resonance imaging (MRI) within 3h of the stroke onset. One day after IVT in neurovascular unit, computed tomography (CT) angiography was performed to assess the brain and the patency of cervical arteries. CEA was performed on neurologically stable patients after full cerebral artery re-canalisation. Blood pressure was controlled with particular caution before and after CEA. RESULTS: Between January 2005 and January 2008, we operated consecutively on 12 patients. Their median National Institutes of Health Stroke Scale (NIHSS) score was 12 (range: 5-21). Combined intracranial (ICA)-middle cerebral artery (MCA) occlusion was present in 58.3% of the patients. The median time between onset of symptoms until CEA was 8 days (range: 1-16 days). Stroke and death rate at 30 days was 8.3% (one nonfatal haemorrhagic stroke). At 90 days, nine patients had a Rankin score of 0-1, one had a score of 2 and two had a score of 3. CONCLUSION: In patients with residual cervical ICA stenosis after IVT, we achieved full patency of the occluded artery and good functional prognosis at 3 months in all cases. We advocate for an extremely close monitoring of the blood pressure in the pre-, peri- and post-operative course and a close collaboration between neurologist and surgeon to determine the best timing for CEA.

The haemodynamics of the distal arterial Y-shaped autograft bypass-flap in a porcine experimental model.

BACKGROUND: The haemodynamic effects of revascularisation with combined bypass and free-muscle flap remain controversial. In a porcine experimental model, we investigated the transplantation-induced changes in the haemodynamics of a Y-shaped combined arterial autograft bypass-muscle flap (AABF). METHODS: Anatomy of AABF was identified in eight dissections in four porcine cadavers. In five animals, AABF served as a superficial femoral artery (SFA) defect replacement. Modelled, triggered pulsatile pressure (P) and flow (Q) waves delivered mean haemodynamics and PQ hysteresis loops before and after transplantation at days 0 and 10. RESULTS: Anatomically, AABF combined subscapular and circumflex-scapular arteries, and thoracodorsal artery as latissimus dorsi flap pedicle. Surgical feasibility and AABF patency were confirmed in each case. At day 0, the proximal flow was increased in the grafted Y-shaped AABF, which also adopted the specific SFA pulsatile haemodynamics. Regulatory mechanisms of AABF vasomotricity were preserved and AABF-flow-dependence amplified the flow in the distal segment, which otherwise preserved its own flow dependence. At 10 days, the AABF flow was unchanged in the distal segment, and remained elevated in the proximal and pedicle segments. CONCLUSIONS: Combined AABF, as a single one-piece arterial autograft, was shown highly adaptive to the receiving arteries. The transplantation-induced changes in AABF pulsatile flow profile and vascular reactivity improve the overall graft flow, and strongly advocate for beneficial effects on the blood propelling capacity of the grafted circulation.

[A pediatric case of rupture of the brachial artery and radial nerve palsy secondary to proximal humeral exostosis]. / Rupture de l'artère brachiale et paralysie radiale secondaire à une exostose proximale de l'humérus chez une enfant de 14 ans.

Rupture of the brachial artery associated with radial nerve palsy in a context of exostosis of the proximal humerus has not been described to date in the literature. Our patient was a fourteen-year-old girl with a history of violent pain occurring suddenly with no prodrome or triggering factor. The pain was localized at the level of the proximal left humerus. Physical examination revealed the presence of a hematoma and complete motor radial nerve palsy. The diagnosis was not confirmed by computed tomography with contrast injection but was confirmed by magnetic resonance imaging which eliminated malignant transformation of the exostosis. After checking the neurovascular bundles and evacuating the hematoma, treatment consisted in resection of the exostosis and arterial repair with an autologous venous graft. We discuss the diagnostic and therapeutic challenges which present vascular complications due to exostosis.

Management of small asymptomatic abdominal aortic aneurysms - a review.

The approach for abdominal aortic aneurysms (AAAs) larger than 55 mm is well defined due to the risk of rupture being higher than 10% per year, and a 30-day perioperative mortality rate between 2.5% and 5%. However, the approach for small asymptomatic AAAs is less well defined.There are different definitions given to describe a small AAA. The one the authors accepted and applied is "a localized, permanent and irreversible dilation of the aorta of at least 50% in relation to the normal adjacent infrarenal or suprarenal aorta, with a maximum diameter between 30-55 mm".The investigators of the largest study on small AAAs (United Kingdom Small Aneurysm Trial [UK-SAT]) concluded, in brief, that ultrasound monitoring is the most appropriate solution because the results do not support a policy of surgical restoration for AAAs with a diameter of between 40 mm and 55 mm.The aim of the present review article is to highlight several challenges that could change the limits or create a more flexible deciding factor in the management of AAAs. There are multiple factors that influence surgical decision-making, and the limit on aneurysm diameter that indicates surgery should depend on the patient's age, life expectancy, general status, associated diseases, diameter in relation to body mass, risk factors, sex, anxiety and compliance during the follow-up period. Monitoring is an acceptable alternative for AAAs between 40 mm and 55 mm, and is probably the best solution for high-risk patients. Surgery is the most reasonable solution for patients who are at moderate risk, have a significant life expectancy, are less than 70 to 75 years of age, and/or have aortic aneurysms larger than 50 mm.

Use of topical negative pressure with a lipidocolloid dressing: results of a clinical evaluation.

OBJECTIVE: To evaluate the protection and acceptability of Urgotul wound dressing in the local management of acute or chronic wounds receiving topical negative pressure (TNP) therapy. METHOD: This was a prospective multicentre non-comparative open-label trial. At each dressing change the investigating physician clinically evaluated and photographed the wound. Planimetric measurement was undertaken and wound depth was assessed at the start and end of the treatment. Follow-up was undertaken until deemed clinically unnecessary by the investigator. RESULTS: Sixty-six patients were included (42 acute wounds and 24 chronic wounds) and followed up for an average of 17 days. Dressing changes were deemed entirely painless in 52% of cases (compared with 18% at baseline) and pain between two consecutive dressing changes was absent in 66% of cases (34% at baseline). Removal of the TNP-interface dressing combination was considered'very easy' or 'easy' in 94% of cases and adherence to the wound was recorded as 'absent' in 88%. On average, the dressings were changed every 3.8 +/- 1.1 days (all wounds were considered), and wound area and depth were reduced by 19% and 54% respectively by the end of the follow-up period. CONCLUSION: Use of the interface dressing in combination with TNP substantially reduced the pain caused by dressing changes. It therefore makes more acceptable the use of this technique, which aims to optimise the management of wounds that are sometimes considered to be in a therapeutic impasse.

'Pole test' measurements in critical leg ischaemia.

BACKGROUND: For the quantification of critical limb ischaemia (CLI) most vascular surgery units use sphygmo-manometric and transcutaneous oxygen pressure (TcPO2) measurements. However, measurements obtained by cuff-manometry can be overestimated especially in diabetic patients because of medial calcification that makes leg arteries less compressible. TcPO2 measurements present a considerable overlap in the values obtained for patients with different degrees of ischaemia and its reproducibility has been questioned. Arterial wall stiffness has less influence on the pole test, based on hydrostatic pressure derived by leg elevation, and this test seems to provide a reliable index of CLI. OBJECTIVE: The objective of this study was to evaluate the pole pressure test for detection of critical lower limb ischaemia, correlating results with cuff-manometry and transcutaneous oxygen pressure. DESIGN: University hospital-prospective study. MATERIALS AND METHODS: Seventy-four patients (83 legs) with rest pain or gangrene were evaluated by four methods: pole test, cuff-manometry, TcPO2 and arteriography. CLI was present if the following criteria were met: (a) important arteriographic lesions+rest pain with an ankle systolic pressure (ASP) < or = 40 mmHg and/or a TcPO2 < or = 30 mmHg, or (b) important arteriographic lesions+tissue loss with an ASP < or = 60 mmHg and/or a TcPO2 < or = 40 mmHg. Fifty-seven lower limbs met the criteria for CLI. RESULTS: Measurements obtained by cuff-manometry were significantly higher to those obtained by pole test (mean pressure difference: 40 mmHg, p<0.001). The difference between the two methods remained statistically significant for both diabetics (50.73, p<0.001) and non-diabetics (31.46, p<0.001). Mean TcPO2 value was 15.51 mmHg and there was no important difference between patients with and without diabetes. Overall, there was a correlation between sphygmomanometry and pole test (r = 0.481). The correlation persisted for patients without diabetes (r = 0.581), but was not evident in patients with diabetes. Correlation between pole test and TcPO2 was observed only for patients with diabetes (r = 0.444). There was no correlation between cuff-manometry and TcPO2. The pole test offered an accuracy of 88% for the detection of CLI. The sensitivity of this test was 95% and the specificity 73%.

Surgical anatomy of the lateral supramalleolar flap in arteritic patients: an anatomic study of 24 amputation specimens.

The lateral supramalleolar flap (LSMF) is frequently used for covering major tissue defects of the foot and ankle but usually, in case of arteriopathy of the lower limbs, this device is contra-indicated. Twenty-four specimens of amputated limbs of patients suffering from arteriopathy of the lower limbs allowed us to study the vascular anatomy of this flap after intra-arterial injection of colored latex. At the time of the amputation the average age of the patients was 68.5 years. The clinical signs of arteriopathy had been present for 3-16 years. In 10 cases the amputation was performed directly, in 14 cases after an unsuccessful attempt at revascularization. The dissection results revealed certain specificities in the vascularization of the LSMF with arteriopathy. The perforating branch of the peroneal artery was found in all cases. The descending branch of this perforating artery was found to be patent in 22 cases but slim in five cases. It was absent in two cases. The superficial peroneal nerve and its vascular network always participated in the vascularization of the flap. Thus, its preservation in the distal part of the flap offers a second vascular flow to the pedicle of the LSMF. This specificity increases the theoretical feasibility of the LSMF from 17 to 22 cases out of 24 in our dissections. The authors suggest a theory according to which the evolution of arteriopathy and the gradual concomitant development of a supply network, which effects the vascularization of the sensory nerves too, induces the "anticipation" of a flap. The preliminary distal revascularization by bypass grafts or by some kind of endovascular treatment should guarantee the good vascularization of a limb and the reliable use of this neurocutaneous arterial network.

[Osteogenic exostosis of the capitate bone. Case report and review of the literature]. / L'exostose ostéogénique du capitatum. Présentation d'un cas et revue de la littérature.

The occurrence of an osteochondroma in the carpus is very rare and its excision is indicated in the case of significant symptoms or change in its appearance. The diagnosis is often made in adulthood due to the onset of a functional problem even though development of the tumour occurs during skeletal growth. We report the case of a 38 year old patient, with no antecedent trauma, who presents with simultaneous exostoses on the dorsal and palmar surfaces of the capitate, which has not been previously described in the literature. The existence of a bipolar lesion extending anteriorly and posteriorly in the carpus is a possibility which may not be apparent and renders plain radiograph insufficient in the investigation of such a lesion. CT scan and MRI scan are indispensable in the investigation of this kind of carpal lesions, allowing better visualization of the base of the tumour, the expansion of the tumour and relation to the neighbouring soft tissues and the presence of malignant degeneration.

Endovascular treatment of occlusive lesions in the distal aorta: mid-term results in a series of 31 consecutive patients.

The purpose of this study was to evaluate the early and mid-term results of endovascular treatment of occlusive lesions in the distal aorta in a consecutive series of patients. Between February 1996 and March 1999, a total of 31 patients underwent transluminal procedures for treatment of occlusive atherosclerotic lesions located at the lower end of the aorta. Thirty patients presented with intermittent claudication and one had critical ischemia. Manifestations were bilateral in 26 cases and unilateral in 5. The lesion was confined to the lower aorta in 3 patients and extended to the common iliac arteries in 19, with predominant proximal lesions of the common iliac artery occurring in 9 patients. Fourteen patients had concurrent infracrural occlusive lesions. All patients underwent exclusive endovascular treatment without any associated open surgical procedure. The three patients with isolated aortic lesions were treated by angioplasty, followed by stent placement in two cases. The 19 patients with aortobiiliac lesions were treated by bilateral common iliac artery angioplasty according to the "kissing-balloon" technique; 7 of these patients also underwent aortic angioplasty. In these 19 patients, aortic stenting was performed in 3 cases and bilateral iliac stenting in 10 cases, including 3 in association with aortic stenting. The nine patients with a proximal lesion of the common iliac arteries were treated by angioplasty, followed by bilateral stenting in three cases and unilateral stenting in three cases. The findings of this study show that the mid-term anatomical and functional results of endovascular treatment for atherosclerotic lesions of the distal aorta are satisfactory. We recommend it as the initial treatment modality.

[Partial replantation following proximal limb injury]. / Réimplantations partielles après traumatisme proximal des membres.

PURPOSE OF THE STUDY: Proximal replantation is a technically feasible but life-threatening procedure. Indications must be restricted to patients in good condition with a good functional prognosis. The goal of replantation must be focused not only on reimplanting the amputated limb but also on achieving a good functional outcome. For the lower limb, simple terminalization remains the best choice in many cases. When a proximal amputation is not suitable for replantation, the main aim of the surgical procedure must be to reconstruct a stump long enough to permit fitting a prosthesis preserving the function of the adjacent joint. If the proximal stump beyond the last joint is very short, it may be possible to restore some length by partial replantation of spared tissues from the amputated part. We present here the results we obtained following this policy. MATERIALS AND METHODS: This series included 16 cases of partial replantations, 14 involving the lower limb and 2 the upper limb. All were osteocutaneous microsurgical transfers. For the lower limb, all transfers recovered protective sensitivity following tibial nerve repair. The functional calcaeoplantar unit was used in 13 cases. The transfer of this specialized weight bearing tissue provided a stable distal surface making higher support unnecessary. In one case, we raised a 13-cm vascularized tibial segment covered with foot skin for additional length. For the upper limb, the osteocutaneous transfer, based on the radial artery, was not reinnervated, but this lack of sensitivity did not impair prosthesis fitting. RESULTS: One vascular failure was finally amputated. This was the only unsuccessful result. For all other patients, the surgical procedure facilitated prosthesis fitting and preserved the proximal joint function despite an initially very proximal amputation. DISCUSSION: The advantages of partial replantation are obvious compared with simple terminalization or secondary reconstruction. There is no secondary donor site and, because there is no major muscle mass in the distal fragment, the overall risk is very low compared with the risk of total proximal leg replantation.