Encountering the corona mortis vessel during laparoscopic totally extraperitoneal mesh hernioplasty and its significance.

Corona mortis (CM) is an anastomotic vessel between the inferior epigastric or external iliac vessels and the obturator or internal iliac vessels. The Latin meaning of it is 'crown of death' which corresponds to massive haemorrhage caused by injury to this vessel during surgery. The incidence of this vessel is around 50% in the hemipelvis. We are presenting an intraoperative video of a right laparoscopic totally extraperitoneal mesh hernioplasty demonstrating a CM artery in the right hemipelvis. Care was taken to prevent injury to this vessel. CO2 insufflation pressure was reduced to less than 10 mm Hg to see any venous variant of this vessel. Carefully, polypropylene mesh was placed without a fixation device. Anatomical knowledge of the CM vessel is therefore essential in preventing injury for surgeons who approach the inguinal and retropubic regions.

Endovascular repair of an abdominal aortic aneurysm with external iliac artery occlusion using VBX as the contralateral leg via axillary delivery: A case report.

RATIONALE: A hostile iliac access route is an important consideration when enforcing endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAA). Herein, we report a case of AAA with unilateral external iliac artery occlusion, for which bifurcated EVAR was successfully performed using a single femoral and brachial artery access. PATIENT CONCERNS: A 76-year-old man who had undergone surgery for lung cancer 4.5 years prior was diagnosed AAA by computed tomography (CT). DIAGNOSIS: Two and a half years before presentation, CT revealed an infrarenal 48 mm AAA, which had enlarged to 57 mm by 2 months preoperatively. CT identified occlusion from the right external iliac artery to the right common femoral artery, with no observed ischemic symptoms in his right leg. The right external iliac artery, occluded and atrophied, had a 1 to 2 mm diameter. INTERVENTION: Surgery was commenced with the selection of a Zenith endovascular graft (Cook Medical) with an extended body length. Two Gore Viabahn VBX balloon expandable endoprosthesis (VBX; W.L. Gore & Associate) were delivered from the right axilla as the contralateral leg. OUTCOMES: CT scan on the 2nd day after surgery revealed no endoleaks. LESSONS: While the long-term results remain uncertain, this method may serve as an option for EVAR in patients with unilateral external iliac artery occlusion.

Superficial Circumflex Iliac Artery Perforator Flap Reconstruction of the Upper Extremity.

The superficial circumflex iliac artery perforator (SCIP) flap is thin, pliable tissue well suited for reconstruction of injuries of the hand and upper extremity. Based upon perforators from the superficial circumflex iliac artery, the SCIP flap has advantages over the traditional groin flap due to reduced need for secondary procedures and improved donor site morbidity This article offers a detailed exploration of the SCIP flap design and technique, its advantages over traditional methods, and its potential applications in reconstructive surgery. Post-operative care and critical points are also discussed, and case examples are provided to guide readers through the intricacies of the technique, emphasizing the surgical skill and precision required for successful implementation.

High-frequency ultrasound-assisted perforator mapping enhances efficiency in microsurgical reconstruction using thin ALT and SCIP flaps.

BACKGROUND: With the growing demand for the use of thin perforator flaps, obtaining knowledge on the superficial anatomy of perforators is imperative for stable flap elevation. Conventional modalities for perforator mapping fall short in providing such information. High-frequency ultrasound (HFUS), known for visualizing the superficially located anatomic structures, may potentially fill this void. This study aimed to evaluate the effectiveness of HFUS in the outcome of anterolateral thigh (ALT) and superficial circumflex iliac artery perforator (SCIP) flap-based reconstructions. METHODS: Consecutive patients who underwent free ALT or SCIP flap-based reconstruction from January 2021 to November 2022 were retrospectively reviewed. Perforator mapping was conducted using a handheld Doppler during the first year, while HFUS was used in the latter part. The two techniques were compared in terms of flap harvesting time and perfusion-related complication rates while considering the flap elevation plane. RESULTS: In total, 123 cases were analyzed, including 82 ALT flaps (41 in each group) and 41 SCIP flaps (16 in the Doppler and 25 in the HFUS group). The time required for flap elevation exhibited a tendency to decrease in the HFUS group, with a significant difference observed in cases involving thin flap elevation (super-thin ALT flaps and pure-skin-perforator SCIP flaps). Compared with the Doppler group, the HFUS group demonstrated significantly lower rates of PRCs, particularly partial flap necrosis. This difference remained significant in multivariable analyses. CONCLUSION: Our results suggest that HFUS might be an appealing modality for perforator mapping in cases requiring thin ALT and SCIP flap.

[Choice of hybrid interventions for iliac-femoral arterial lesions]. / Vybor ob"ema gibridnogo vmeshatel'stva pri porazhenii arterii podvzdoshno-bedrennogo segmenta.

OBJECTIVE: To compare the short-term and long-term outcomes of hybrid interventions after various infrainguinal reconstructions (restoration of blood flow through superficial femoral artery and pulsatile blood flow through deep femoral artery) in patients with iliac-femoral arterial disease. MATERIAL AND METHODS: A retrospective analysis included patients after hybrid iliac-femoral interventions between 2014 and 2018. These interventions included stenting of iliac arteries and various open infrainguinal reconstructions. The first group (n=41) consisted of patients who underwent reconstruction of superficial femoral artery, the second group (n=88) - restoration of pulsatile blood flow in deep femoral artery. We analyzed the Rutherford score, perioperative complications, primary patency rates and limb salvage rates after 12 months in both groups. RESULTS: Significant improvement (Rutherford score +3) was achieved in 28 (70%) and 14 (15.9%) patients, respectively (p<0.05). There were no significant between-group differences in the number of postoperative complications. Surgery time was longer in the first group (median 160 and 130 min, respectively, p<0.05). However, intraoperative blood loss was similar. Primary patency rates after 12 months were 82.4% and 95.1%, respectively (p=0.054). Limb salvage rates after 12 months were 94.7% and 100%, respectively (p<0.05). CONCLUSION: This study highlights the potential advantages of restoring pulsatile blood flow through the deep femoral artery in hybrid interventions. Higher primary patency and limb salvage rates in the second group indicate better long-term outcomes after restoration of blood flow through the deep femoral artery. Further prospective studies are needed to confirm these results and determine the underlying mechanisms of differences.

Pedicled chimeric superficial circumflex iliac artery perforator (SCIP) flap with external oblique fascia for vesicocutaneous bladder fistula repair: A case report and literature review on the utility of pedicled chimeric SCIP.

Following its initial description by Koshima in 2004, the superficial circumflex iliac artery perforator (SCIP) flap has become a ubiquitous and extremely useful flap in coverage of defects whereby bulkiness must be avoided. It also allows direct closure and concealment of the donor site. Its use as a free tissue transfer has been demonstrated by various surgeons globally. Nevertheless, there are few cases illustrating the utility of the pedicled SCIP flap in the reconstruction of lower abdominal defects. We present a case of a pedicled SCIP flap utilized as a chimeric flap incorporating external oblique muscle fascia on a deep branch along with the typical fasciocutaneous component based on the superficial branch to cover the suprapubic defect after vesicocutaneous fistula repair. We thereafter report on the literature of pedicled chimeric SCIP flap for locoregional reconstruction. A 26-year-old female was referred to the Plastic and Reconstructive Surgery unit after suffering a functional bladder outlet obstruction necessitating the creation of a urinary stoma. Subsequently, stoma obstruction occurred, and a suprapubic catheter was performed that was complicated by infection and resulted in the development of a vesicocutaneous fistula. Accordingly, the urological surgeons were planning surgical closure of the suprapubic vesicocutaneous defect, measuring 5 × 4 cm. A pedicled SCIP flap was designed to match the defect size; and raised as a chimeric flap with external oblique muscle fascia based on the deep branch, along with the fasciocutaneous component based on the superficial branch. The external oblique fascial component was used to secure the suture line of fistula repair, over which the fasciocutaneous component was inset, effectively double breasting the fistula repair and full thickness lower abdominal defect. The patient had an unremarkable postoperative recovery and has since been followed up in the outpatient setting without complication for the past 24 months. Robust coverage of the suprapubic defect was reliably achieved and no further fistulation has occurred. This case illustrates that a pedicled SCIP flap can be harvested as a chimeric flap and used to reliably cover defects in the infra-umbilical region.

Interposition of right internal iliac artery free-graft for left coronary artery reimplantation in adults with anomalous left coronary artery originating from the pulmonary artery: case series and long-term results.

Anomalous left coronary artery originating from the pulmonary artery (ALCAPA) is an infrequent congenital anomaly. Presentation of this syndrome is rare in adults. Nevertheless, adult patients are at risk of ischaemia, arrhythmias or sudden cardiac death and always require surgical intervention. At our institution, a specific technique of interposition of the right internal iliac artery as a free-graft for left coronary artery reimplantation was used in adult ALCAPA patients. The aim of this report is to determine long-term results and experiences with this surgical technique.

Immunoglobulin G4-Related Disease Complicating Ruptured Isolated Iliac Artery Aneurysm: A Complex Management Dilemma.

BACKGROUND Managing IgG4-related disease (IgG4-RD) in the context of vascular complications, such as aneurysms, poses significant challenges, particularly when considering surgical intervention options. The risk of rupture and infection in patients on long-term glucocorticoid therapy complicates treatment decisions. CASE REPORT A 63-year-old woman with a history of IgG4-RD presented with a ruptured right iliac artery aneurysm. She was on long-term oral glucocorticoid therapy. Initial emergency endovascular stent graft implantation was followed by embolization for suspected arterial bleeding and subsequent Salmonella bacteremia. Repeated hospitalizations involved stent graft removal and surgical repair due to persistent infection. Over 2 years, the patient required multiple pelvic drainages and long-term antibiotic and prednisolone therapy, yet her quality of life remained compromised. CONCLUSIONS Our case highlights the unique challenges and considerations in the treatment of IgG4-related aneurysms. Patients with IgG4-RD who are on long-term oral glucocorticoids have an inherent risk of aneurysm rupture. We believe regular follow-ups to monitor the progression of the aorta and iliac arteries into aneurysms are essential. For patients who have developed aneurysms, it is advisable to reduce the dosage of glucocorticoids or even consider surgical treatment as soon as possible. As for the choice of surgical method, there is no consensus yet. While endovascular treatment is less invasive and quicker, it can increase the risk of rupture and bleeding. Open surgery might be a better option. More data are needed to make a definitive judgment.

Iliac artery stent dislodgement: a rare transcatheter aortic valve implantation complication.

An 82-year-old male patient with severe, symptomatic aortic stenosis was referred for transcatheter aortic valve implantation.

[Clinical effects of free superficial circumflex iliac artery superficial branch perforator flap combined with full-thickness skin graft far from the flap donor site in repairing the large wounds in extremities].

Objective: To investigate the clinical effects of free superficial circumflex iliac artery (SCIA) superficial branch perforator flap combined with full-thickness skin graft far from the flap donor site in repairing the large wounds in extremities. Methods: The study was a retrospective observational study. From January 2020 to June 2022, 19 patients with large wounds in extremities who met the inclusion criteria were admitted to the First Affiliated Hospital of Bengbu Medical College, including 15 males and 4 females, aged 28-75 years. The debridement, fracture reduction and fixation, tendon, vessel, and nerve repair, and vacuum sealing drainage were performed in the first stage surgery. After debridement in the second stage surgery, the total wound area was 13.0 cm×8.0 cm-34.0 cm×15.0 cm. The tendon and bone exposed wound with area of 9.0 cm×6.0 cm-14.0 cm×7.0 cm was repaired with free SCIA superficial branch perforator flap with area of 10.0 cm×6.5 cm-15.0 cm×8.0 cm. The remaining granulation tissue wound with area of 5.0 cm×3.5 cm-13.0 cm×8.0 cm was repaired with full-thickness skin graft far from the flap donor site with area of 5.0 cm×3.5 cm-13.0 cm×8.0 cm. All the wounds in donor site were sutured. The operation time and amount of bleeding of patients during the surgery were recorded, the survival of flap and skin graft were observed after surgery. During follow-up, the flap and skin graft, scar in the donor site and its effect on donor site function were observed. At the last follow-up, the satisfaction of patients with the efficacy was evaluated by the efficacy satisfaction rating score. Results: The operation time of patients was 2.0-3.5 h. The amount of bleeding of patients during the surgery was 100-320 mL. One patient had ecchymosis and venous crisis in the edge of flap on the second day after surgery, and the flap survived after exploration. The flaps of the other patients survived smoothly. The skin grafts of patients all survived smoothly. Two patients had bloated flaps due to obesity in the later stage, and the expected results were achieved after flap thinning surgery 6 months after operation. During the follow-up of 6 to 24 months, the flaps had good elasticity and soft texture, and the skin grafts had no wear or ulceration; linear scars were left in all the donor sites but their functions were not affected. The patients were all satisfied with the efficacy. Conclusions: Free SCIA superficial perforator flap combined with full-thickness skin graft far from the donor site was used to repair the large wounds in extremities, which was safe, reliable, and less traumatic and short in operation time, and resulted in good postoperative appearance and function in the donor sites and recipient sites.

Kidney transplantation using ipsilateral arterial and contralateral venous anastomosis in a patient with failing vascular access.

Herein, we describe our surgical technique and outcome of a kidney transplant in a patient with failing vascular access. A right donor kidney was transplanted into the right iliac fossa with an end-to-side arterial anastomosis to the ipsilateral right common iliac artery and end-to-side venous anastomosis to the contralateral left common iliac vein. The possibility of performing an ipsilateral arterial and contralateral venous anastomosis has been shown here to be successful. No post-operative surgical complications were encountered.

Deep Circumflex Iliac Artery Flap Reconstruction in Brown Class I Defect of the Mandible Using a Three-Component Surgical Template System.

BACKGROUND: Computer-assisted surgery is widely used in mandibular reconstruction, but the process is not well described for cases using the deep circumflex iliac artery flap (DCIA) as the donor site. This study aimed to present a DCIA-based three-component surgical template system (3-STS) in patients with a mandibular Brown class I defect. METHODS: This retrospective cohort study compared clinical outcomes of mandibular reconstruction with DCIA flap using 3-STS or conventional surgical templates. The primary outcome of the study was the accuracy of reconstruction, and the secondary outcomes included surgical time and bone flap ischemia time. Surgery-related parameters and functional outcomes were also recorded and compared. RESULTS: Forty-four patients (23 in the 3-STS group and 21 in the control group) between 2015 and 2021 were included. Compared with the control group, the 3-STS group had higher accuracy of reconstruction, indicated by lower deviation in absolute distance (1.45 ± 0.76 mm versus 2.02 ± 0.89 mm; P = 0.034), and less deviation in coronal and sagittal angles (0.86 ± 0.53 degree versus 1.27 ± 0.59 degrees, P = 0.039; and 2.52 ± 1.00 degrees versus 3.25 ± 1.25 versus, P = 0.047) between preoperative and postoperative computed tomographic imaging. Surgical time and bone flap ischemia time were significantly reduced in the 3-STS group compared with the control group (median time, 385 minutes versus 445 minutes and 32 minutes versus 53 minutes, respectively; P < 0.001). In addition, masseter attachment was preserved in the 3-STS group but not in the control group. No differences were found in adverse events or other clinical variables. CONCLUSION: The 3-STS can improve accuracy, simplify intraoperative procedures to increase surgical efficiency, and preserve functionality in mandibular reconstruction for Brown class I defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Venous anatomy of the superficial circumflex iliac artery perforator flap: A cadaveric and clinical study.

BACKGROUND: Reconstructive surgeons frequently face challenges with free tissue transfer when transplanted flaps are thicker than intended. This is especially pronounced in lower limb cases, where the soft tissue below the knee is thin. The supra-fascial superficial circumflex iliac perforator (SCIP) flap overcomes this problem, but venous congestion remains a concern. We aim to examine the venous anatomy of the SCIP flap through cadaveric dissections and clinical data analyses to enhance the understanding of the venous anatomy and reduce venous congestion in future procedures. METHODS: Eight cadaveric groins underwent venous dye injection and dissection to identify the superficial circumflex iliac vein (SCIV) and venae comitantes (VC) vascular networks. The venous anatomy was studied for dominant drainage. From April 2015 to December 2019, we conducted 102 SCIP flap reconstructions, mainly using the superficial circumflex iliac artery's superficial branch. Clinical data were analyzed and correlated with cadaveric dissections. SCIP flaps were categorized into three groups: dual drainage (VC and SCIV) in group I, SCIV-only in group II, and VC-only in group III. RESULTS: Correlations between clinical cases and cadaveric dissections revealed the SCIV as an independent drainage system with oscillating links to the VC. The SCIV is approximately twice the diameter of the VC, and the area of each vascular network suggests codominance. No significant difference in flap loss or venous congestion rates was noted when SCIV was the sole drainage, compared with VC or dual drainage. CONCLUSION: The SCIP flap with one artery and SCIV anastomosis, exhibits low venous congestion rates. Surgeons should consider SCIV for safe SCIP flap reconstruction.

Comparison of laparoscopic lateral lymph node dissection for rectal cancer with and without routine resection of the visceral branches of internal iliac artery.

PURPOSE: This study aimed to explore the safety and feasibility of the modified lateral lymph node dissection (LLND) with routine resection of the visceral branches of internal iliac vessels (IIVs) for mid-low-lying rectal cancer. MATERIALS AND METHOD: Consecutive patients undergoing LLND for rectal cancer were divided into the routine visceral branches of the IIVs resection group (RVR group) and the NRVR group (without routine resection). The main outcomes were postoperative complications and the number of lateral lymph nodes harvested. RESULTS: From 2012 to 2021, a total of 75 and 57 patients were included in the RVR and NRVR group, respectively. The operative time was reduced in the RVR group (p = 0.020). No significant difference was observed between the two groups for the incidence of total, major, or minor postoperative complications. Pathologically confirmed LLNM were 24 (32%) patients in the RVR group and 12 (21.1%) in the NRVR group (p = 0.162). The number of lateral lymph nodes harvested had no significant difference between two groups (11 vs. 12, p = 0.329). CONCLUSION: LLND with routine resection of visceral branches of IIVs is safe and feasible, which brings no major complication or long-term urinary disorder.

Safety and efficacy of kidney transplantation in patients with aortoiliac stenosis: a retrospective cohort study.

BACKGROUND: The impact of aortoiliac occlusive disease on kidney transplantation remains unclear. This study aims to investigate the clinical outcomes of kidney transplant patients with aortoiliac atherosclerotic stenosis. METHODS: Retrospective data from our transplant center were used to identify patients undergoing kidney transplantation between January 2010 and December 2020. Aortoiliac atherosclerotic stenosis was screened and stratified by the Trans-Atlantic Inter-Society Consensus (TASC) II classification. The primary outcome was patient survival. Secondary outcomes were 90-day mortality, death-censored graft survival, graft function, and arterial complications. Propensity score matching was used to match all patients in the stenosis group with patients without stenosis sharing similar characteristics. RESULTS: The analysis included 655 patients, 524 without stenosis and 131 with aortoiliac stenosis (95 with TASC A/B stenosis and 36 with TASC C/D stenosis). Recipient age [median (IQR), 66 (60-70) vs. 66 (59-71) years; P =0.47], sex [male: 87 (66%) vs. 355 (68%), P =0.85], and comorbidities were comparable between the stenosis and no-stenosis groups. Forty-six (35%) patients with stenosis were symptomatic. Patient survival was significantly lower in the stenosis group compared with the no-stenosis group (TASC A/B: 30.6% vs. no-stenosis: 44.1%, P =0.013; TASC C/D: 11.4% vs. no-stenosis: 44.1%, P <0.001). The incidence rates of artery dissection, lower extremity ischemia, and acute thrombosis were significantly higher in the stenosis group ( P <0.001). However, death-censored graft survival (TASC A/B: 73.6% vs. no-stenosis: 72.9%, P =0.62; TASC C/D: 58.1% vs. no-stenosis: 72.9%, P =0.16) and graft function were comparable between the groups. CONCLUSIONS: Aortoiliac atherosclerotic stenosis significantly impacts patient survival but not graft survival. Our analyses suggest that patients with TASC A/B stenosis have prolonged survival and enhanced quality of life through kidney transplantation. However, for patients with TASC C/D stenosis, kidney transplantation improves quality of life without bringing survival benefits.

Intravascular flipping technique for end-to-side microvascular anastomosis.

Recent advances in minimally invasive perforator flaps, such as the superficial circumflex iliac artery (SCIP) flap, have increased the demand for anastomosing vessels with diameters less than 0.8 mm. However, discrepancies in size can occur, underscoring the significance of end-to-side anastomosis. Nevertheless, the conventional interrupted end-to-side suturing technique with vessel turnover presents challenges in situations with a limited operative field, short vascular pedicle, and tiny vessels. Therefore, we developed an intravascular flipping technique for end-to-side microvascular anastomosis with an inside technique or rotation-outside technique. The study involved 20 rats and with 15 arteries in 10 rats undergoing the flipping technique with inside or outside rotation. Both the inside and rotation-outside techniques exhibited a 100% immediate patency rate in the rats; however, after 1 week, this decreased to 80% and 86%, respectively. The SCIP flap and replantation procedures were successfully performed. The flipping technique offers several advantages, including ease of vessel manipulation using nylon threads and vascular clips, improved vessel visualisation, and spontaneous widening of the vessel lumen.