Does anticoagulation improve outcomes of microvascular free flap reconstruction following head and neck surgery: a systematic review and meta-analysis.

The commonest cause of microvascular free flap failure is thrombosis at the anastomosis. Pharmacological antithrombotic therapies have been used to mitigate this risk, but they carry the risk of bleeding and haematoma formation. To justify any intervention, it is necessary to evaluate the benefits and balance of risks. This meta-analysis aims to quantify the value of systemic anticoagulation during head and neck free tissue reconstruction. We performed a systematic review on the impact of additional prophylactic antithrombotic therapy on head and neck (H&N) free tissue transfer (on top and above the use of low molecular weight heparin to prevent deep vein thrombosis). We carried a PRISMA-guided literature review, following registration with PROSPERO. All studies analysing the possible impact of prophylactic anticoagulants on free flap surgery in the head and neck were eligible. The primary outcome was perioperative free flap complications (perioperative thrombosis, partial or total free flap failure, thrombo-embolic events, or re-exploration of anastomosis). Secondary outcomes included haematoma formation or bleeding complications requiring further intervention. We identified eight eligible studies out of 454. These included 3531 free flaps for H&N reconstruction. None of the assessed interventions demonstrated a statistically significant improvement in free flap outcomes. Accumulative analysis of all anti-coagulated groups demonstrated an increased relative risk of free flap complications [RR 1.54 (0.73-3.23)] compared to control albeit not statistically significant (p = 0.25). Pooled analysis from the included studies showed that the prophylactic use of therapeutic doses of anticoagulants significantly (p = 0.003) increased the risk of haematoma and bleeding requiring intervention [RR 2.98 (1.47-6.07)], without reducing the risk of free flap failure. Additional anticoagulation does not reduce the incidence of free flap thrombosis and failure. Unfractionated heparin (UFH) consistently increased the risk of free flap complications. The use of additional anticoagulation as 'prophylaxis' in the perioperative setting, increases the risk of haematoma and bleeding.

Situational awareness in driving, and lessons for surgeons.

It is often said that medicine could learn a lot from aviation. Human and system errors affect all complex organisations including healthcare, and there is increasing awareness of the role of non-technical skills in the safe practice of surgery. Comparisons are often drawn between the way in which the aviation industry learns from errors and the paucity of learning from errors in situational judgement in medical practice. Although many of us travel on planes, very few of us fly them, but most surgeons drive regularly. We review a series of motoring incidents that demonstrate poor situational awareness and judgement, and discuss the incidents, predisposing causes, and their relevance to medical practice. These errors are transferrable to medical practice, and perhaps we can learn from them.

The incidental finding of a retained 'throat pack'.

A postoperative radiograph demonstrated a folded radio-opaque structure in the nasopharynx, resembling a retained throat pack, despite her not having any respiratory symptoms. Retention of a throat pack is a never event.

Gillies temporal incision: an alternate approach to superficial temporal artery biopsy.

The main complications of a biopsy of the superficial temporal artery using a standard preauricular approach include scars on the face, weakness of the temporal branch of the facial nerve, and the possible harvest of a disease-free segment of artery. We describe a modification of the Gillies temporal approach, which when placed at the junction of the frontal and parietal branch can be easily modified to harvest either branch. It avoids scarring to the face as it is hidden within the hairline. The incision placed with specific measurements and palpation is easily reproducible. In patients with giant cell arteritis, arterial wall thickening, and narrowing of the lumen, reduced blood flow makes it harder to identify the artery with a Doppler scan. A procedure based on measurements and palpation is therefore likely to yield better results.

Cast-cap splint in the management of medication-related osteonecrosis of the jaw.

We describe the management of a pathological fracture in a patient with medication-related osteonecrosis using a cast-cap splint. In selected cases this is a simple solution to what can be a difficult condition to treat.

Outcome of aortoiliac, femoropopliteal and infrapopliteal endovascular interventions in lesions categorised by TASC classification.

AIM: To analyse lower limb angioplasty results using the defined anatomical classification of the Trans-Atlantic Inter-Society Consensus (TASC) in a training environment and to compare the results with published data. MATERIALS AND METHODS: Retrospective, consecutive data were collected for a period of 1 year for all patients undergoing lower limb endovascular interventions. The radiology information system and notes were used to obtain clinical data, and angiograms were reviewed in all cases. All cases were performed or supervised by five vascular interventional consultants assisted by fellows or registrars. Patient demographics, the indication for treatment, the TASC classification of the treated lesion, calcification, use of stent, technical success (residual stenosis <20% on completion angiography), and complications were assessed. RESULTS: Two hundred and sixty-two lesions were treated. Of the aortoiliac lesions (83), the overall primary technical success rate was 91.6% (TASC A and B: 96.7%, TASC C and D: 77.3%). Sixty-one lesions were stented and no complications recorded. Of the femoropopliteal lesions (n = 123), the overall primary technical success rate was 91.9% (TASC A and B: 98.7%, TASC C and D: 80.9%). There were four major and five minor complications in this group (five groin haematomas, two vessel ruptures, one retroperitoneal haematoma, and one distal embolization). Five patients were stented. In the infrapopliteal group (n = 56), the overall primary technical success rate was 91.1% (TASC A and B: 96.3%, TASC C and D: 86.2%). There was one complication (small retroperitoneal hematoma) and two stents were used. CONCLUSION: The results of the present study showed good technical success and low complication rates in lower limb endovascular interventions with variable operator expertise. The results are comparable to published data. Use of the TASC classification system is encouraged as it allows an objective assessment of severity and enables standardized comparison.

Developments in subintimal angioplasty in the infrainguinal segment.

Since it was first described in 1990, subintimal angioplasty (SIA) has become an established percutaneous procedure for the treatment of symptomatic lower limb arterial occlusions. The concept of this technique is to create a dissection in the subintimal plane in order to cross an occluded intraluminal segment, then to re-enter the true lumen of the patent distal artery. Balloon dilatation of this subintimal channel results in a new extraluminal lumen that is free of atheromatous plaque. It is a safe and effective procedure with advantages over intraluminal angioplasty and open surgery, thereby increasing the scope of endovascular therapy to include complex infrapopliteal occlusions and high-risk patients with limb-threatening ischaemia who are unsuitable for surgical revascularization. It has good primary success rates, long-term outcomes and does not compromise future surgical revascularization, resulting in a paradigm shift in the management of lower limb ischemia with many centres adopting SIA as first-line therapy. This article aims to review the indications of SIA, variations and developments in the technique, outcomes and factors affecting patency, and complications associated with the procedure.

Below the knee angioplasty among diabetic patients.

The treatment of below knee arterial disease has undergone a gradual shift over the last few years to incorporate a greater proportion of endovascular treatments. Not only does this include patients who now have endovascular therapy rather than surgery, but also patients who in the past would have been offered supportive treatment only, due to factors such as being medically unfit for surgery, lacking sufficient donor vein for bypass grafting, or swelling. Diabetes mellitus is becoming increasingly common, potentially causing numerous comorbidities in patients. It tends to have a more distal pattern of peripheral vascular disease, presenting later and with generally high complication and failure rates following therapy (surgical or endovascular) and higher amputation rates. Given these comorbidities, the reduced morbidity and mortality of endovascular treatments may be beneficial in treating below-knee arterial disease. The success and complication rates of endovascular therapy vary between treatment for claudication and critical limb ischaemia, though success rates are improving and in some cases are comparable to the current gold standard of surgical bypass.

Facial atrophy following accidental subcutaneous extrusion of sodium hypochlorite.

Facial atrophy of the buccal fat pad following inadvertent subcutaneous extrusion of sodium hypochlorite is very rare. It is a complication which leaves the patient with a defect which is very difficult to treat. We present the case of a 46-year-old lady who presented with almost complete unilateral atrophy of the buccal fat pad. She has undergone multiple surgeries over the past two years. We highlight the precautions that must be taken to prevent such a complication and the difficulties in rehabilitating such a patient.

An observational cohort study of the management and outcomes of vascular trauma.

OBJECTIVES: To evaluate aetiology, presentation, management and mortality following iatrogenic and non-iatrogenic vascular trauma in a regional vascular centre. METHODS: Retrospective observational cohort study of patients presenting with vascular trauma during a seven year period between January 2000 and December 2006. RESULTS: 182 cases of vascular trauma were identified (averaging 26 cases p.a.). The majority (n=132, 73%) were iatrogenic and tended to occur in patients aged >45 years, while 50 (27%) were penetrating/blunt, non-iatrogenic and predominantly occurred in younger males. The majority of iatrogenic vascular injuries (80/132) (61%) followed a cardiac intervention (angiography n=56, angioplasty n=23, pacemaker insertion n=1) and are now increasingly treated by non-operative therapies (thrombin, coils and covered stents). Overall, non-iatrogenic vascular trauma was associated with 4% mortality, compared with 7% following iatrogenic injury. However, while iatrogenic trauma of cardiological origin was associated with a mortality of only 1.3% (1/80), iatrogenic trauma of non-cardiological origin incurred a mortality of 17% (9/52). CONCLUSIONS: The commonest cause of vascular trauma (and with the lowest mortality rate) was cardiological related iatrogenic injury. However, while non-cardiological iatrogenic injury occurred with the same incidence as penetrating/blunt trauma, it was associated with a fourfold excess mortality.

Revascularization strategies in below the knee interventions.

Until recently the role of endovascular revascularization in the infrapopliteal arteries was limited. Endo-vascular management including percutaneous transluminal angioplasty and subintimal angioplasty is now being considered as a primary alternative in critical limb ischaemia revascularization with a decreasing number of major amputations (above the ankle) performed. Endovascular treatment has been shown to have reduced morbidity and hospital stay compared to revascularization surgery with greater cost-effectiveness and better patient quality of life compared with major amputation.

Subintimal angioplasty in the management of lower limb ischaemia.

It is now almost 20 years since subintimal angioplasty (SIA) was pioneered. This cost-effective technique has over the past few years enjoyed a dramatic resurgence of interest and application, particularly after having been identified as a safe and practicable approach to vascular recanalisation in several international publications. Originally used in the femoropopliteal segment, its role has been extended to the treatment of infrapopliteal lesions, including the recanalization of the trifurcation and long tibial occlusions. Experienced centres have repeatedly reported primary success rates of around 90% in the infrainguinal vessels, as well as 1-year limb salvage rates as high as 85% to 90%, and 5-year primary assisted patency rates of 64% whilst not interfering with subsequent vascular surgery. Indeed SIA has not only proved to be very effective in lower limb ischaemia management, both for intermittent claudication and critical ischaemia, but in the last few years it has moved from the shadows and into the limelight of modern endovascular therapy.