Rare case of divided phrenic nerve variation: a cadaveric case report.

The phrenic nerve innervates the respiratory diaphragm, the primary muscle active during ventilation. The canonical path of the phrenic nerve originates from the cervical spine at C3-C5 spinal nerves and travels inferiorly through the neck and thoracic cavity to reach the diaphragm. During a cadaver dissection, a variation of the phrenic nerve was discovered in a 93-year-old male specimen. A traditional origin of the phrenic nerve was noted; however, the nerve branched into medial and lateral components at the level of the superior trunk of the brachial plexus. The branches reconnected at the apex of the aortic arch and continued inferiorly to innervate the ipsilateral diaphragm. This case study describes a rare type of branching of the phrenic nerve and explores its potential impact on clinical procedures.

Use of EndoAnchors during index endovascular aortic aneurysm repair in patients with hostile proximal aortic neck anatomy.

PURPOSE: Standard endovascular aortic aneurysm repair (EVAR) is sometimes the only treatment option for patients with hostile aortic neck anatomy, but it carries an increased risk of both early and late procedure-related complications. The aim of this study was to report on single-center experience with the Heli-FX EndoAnchors (Medtronic, Santa Rosa, CA) as an adjunctive procedure to endovascular aneurysm repair (EVAR) for prevention and perioperative treatment of proximal neck complications in patients with hostile neck anatomy.  MATERIALS AND METHODS: A single-centre, retrospective study evaluating 24 consecutive patients treated with EndoAnchors during the index EVAR procedure between November 2018 and August 2021. EndoAnchor implantation was indicated for cases with hostile proximal aortic neck anatomy characterised by the presence of at least one of the following parameters: length of 28 mm, angle of >60°, circumferential thrombus/calcification involving ≥50%, and reverse taper. RESULTS:  Median follow-up period was 22.5 months (IQR 2-31.5 months) with no aneurysm-related death, rupture, or conversion to open surgical repair during the follow-up. The procedural success rate was 100%, with no type Ia endoleak at the completion angiography. A mean of 7 EndoAnchors was used per patient (range 4-12). There were no EndoAnchor fractures and dislocations or stent graft fabric damage due to anchor implants. Twenty-three patients (95.8%) remained free of type Ia endoleak and migration on follow-up imaging. Aneurysm sac regression was observed in 13 patients (54.1%), while in 8 patients (33.3%) the sac remained stable. Sac enlargement was present in 1 patient (4.2%) due to late type Ia endoleak. Two patients were lost to the follow-up immediately after the procedure. Between two groups of patients (sac regression versus failure to regress), the larger initial diameter of the proximal neck was the only significant independent factor associated with a lower possibility of sac regression (p= 0,021). CONCLUSIONS:  The use of EndoAnchors during the index EVAR procedure in cases with challenging aortic neck anatomy with or without perioperative type Ia endoleak was associated with good midterm results and led to sac regression in most of the patients (Tab. 4, Fig. 3, Ref. 31).

The Impact of Proximal Neck Anatomy on the 5-Year Outcomes Following Endovascular Aortic Aneurysm Repair With the Ovation Stent Graft.

PURPOSE: Hostile proximal neck anatomy has historically been associated with worse outcomes for endovascular aortic aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA). We investigated the impact of proximal neck anatomy on the outcomes following EVAR with the Ovation abdominal stent graft (Endologix, Irving, Calif). METHODS: We used prospectively collected data from the Effectiveness of Custom Seal with Ovation: Review of the Evidence database, compromised of pooled data from 6 clinical trials and the European Post-Market Registry of patients undergoing elective infrarenal EVAR (2009-2017). We investigated the impact of short neck length (<10 mm), wide neck diameter (≥28 mm), reverse taper shape (>10%), and neck angulation (>45°) on the outcomes. The primary outcome was type IA endoleak. Secondary outcomes included any type I/III endoleak, sac expansion, aneurysm-related reinterventions, and all-cause and aneurysm-related mortality, and a combined endpoint of type IA endoleak, graft migration, AAA-related reintervention, conversion, and aneurysm rupture. We used Kaplan-Meier analysis and Cox proportional hazards models to estimate the 30 day and 5 year rates and assess univariate and risk-adjusted differences. RESULTS: Of the 1020 patients, 60 patients had a short neck, 113 had a wide neck diameter, 279 were reverse taper shaped, and 99 had neck angulation >45°. Wide proximal neck was associated with higher 5 year type IA endoleak estimates compared with favorable neck anatomy (7.1% vs 4.3%; p=0.02). No association with 5 year type IA endoleak was found for short neck length (1.7% vs 4.3%; p=0.52), reverse taper shape (3.2% vs 4.3%; p=0.99), or neck angulation (6.1% vs 4.3%; p=0.13). A wide neck diameter compared with favorable anatomy was also associated with higher 5 year estimates of graft migration (3.8% vs 0.4%; p=0.03) and the combined neck-related adverse outcome endpoint (16% vs 9.5%; p=0.002). The estimates of aneurysm sac expansion, rupture, and overall and aneurysm-related mortality were similar between the hostile proximal neck anatomy cohorts and favorable anatomy. CONCLUSION: Wide proximal neck is associated with higher 5 year type IA endoleak rates for patients treated with the Ovation stent graft. However, short neck length, reverse taper shape, and neck angulation are not associated with higher 5 year type IA endoleak rates. CLINICAL IMPACT: Hostile proximal neck anatomy has historically been associated with worse outcomes for endovascular aortic aneurysm repair of abdominal aortic aneurysms. The Ovation stent graft platform uses a different proximal sealing method using a polymer inflatable ring, aiming to improve sealing between the graft and aortic wall. This study demonstrated that short, angulated, and reverse taper-shaped neck anatomy did not result in increased type IA endoleak estimates in patients treated with the Ovation stent graft platform. Potentially, the different sealing mechanisms played a role in mitigating the historically worse outcomes in patients with short, angulated, and reverse taper-shaped neck anatomy.

Effect of abdominal aortic aneurysm sac shrinkage after endovascular repair on long-term outcomes between favorable and hostile neck anatomy.

OBJECTIVE: The aim of the present study was to analyze the influence of abdominal aortic aneurysm sac shrinkage on the long-term outcomes after endovascular aneurysm repair (EVAR) between patients with favorable and hostile neck anatomy. METHODS: In the present study, we retrospectively analyzed data from 268 patients with fusiform aneurysm and sac behavior who had been evaluated for ≥1 year after EVAR. Hostile neck anatomy was defined as a proximal aneurysmal neck length of <10 mm or proximal neck angle of ≥60°. The primary end point was sac shrinkage, and the secondary end points included reintervention and a composite of rupture, type Ia endoleak, and late open conversion. RESULTS: No differences were found in sac shrinkage between the patients with favorable and hostile neck anatomy (P = .47). Multivariate analysis revealed that an occluded inferior mesenteric artery (P = .04), the presence of posterior thrombus (P < .01), and no antiplatelet therapy (P = .01) were positive factors for sac shrinkage. The reintervention-free survival rate was better for patients with sac shrinkage compared with those without sac shrinkage regardless of the proximal neck anatomy (P < .01). The event-free survival rate of the composite end point at 5 and 10 years was 97.5% and 83.5% for patients with favorable neck anatomy and 86.8% and 81.0% for those with hostile neck anatomy, respectively (P = .02). In the subgroup with sac shrinkage, the event-free survival rates at 5 and 10 years were 98.7% and 98.7% for those with favorable neck anatomy and 92.7% and 82.4% for those with hostile neck anatomy, respectively (P = .02). In contrast, the event-free survival for patients without sac shrinkage did not differ between those with favorable and hostile neck anatomy (P = .08). Multivariate analysis showed that a hostile neck anatomy (hazard ratio, 3.32; 95% confidence interval, 1.26-8.80; P = .02) and no sac shrinkage (hazard ratio, 3.88; 95% confidence interval, 1.25-12.0; P = .02) were significant risk factors for the composite end point of rupture, type Ia endoleak, and late open conversion. CONCLUSIONS: Proximal neck anatomy did not affect sac shrinkage after EVAR. Sac shrinkage has been a good surrogate marker of better long-term outcomes after EVAR for patients with favorable neck anatomy. In contrast, critical events such as rupture and type Ia endoleak can occur even after sac shrinkage has been achieved in patients with hostile neck anatomy.

Endovascular aortic repair with EndoAnchors demonstrate good mid-term outcomes in physician-initiated multicenter analysis-The PERU registry.

OBJECTIVES: We aim to describe real-world outcomes from multicenter data about the efficacy of adjunct Heli-FX EndoAnchor usage in preventing or repairing failures during infrarenal endovascular aneurysm repair (EVAR), so-called EndoSutured-aneurysm-repair (ESAR). METHODS: The current study has been assigned an identifier (NCT04100499) at the US National Library of Medicine (https://ClinicalTrials.gov). It is an observational retrospective study of prospectively collected data from seven vascular surgery departments between June 2010 and December 2019. Patients included in the ANCHOR registry were excluded from this analysis. The decision for the use of EndoAnchors was made by the treating surgeon or multidisciplinary aortic committee according to each center's practice. Follow-up imaging was scheduled according to each center's protocol, which necessarily included either abdominal ultrasound or radiography or computed tomographic scan imaging. The main outcomes analyzed were technical success, freedom from type Ia endoleaks (IaEL), all-cause and aneurysm-related mortality, and sac variation and trends evaluated for those with at least six months imaging follow-up. RESULTS: Two hundred and seventy-five patients underwent ESAR in participating centers during the study period. After exclusions, 221 patients (184 males, 37 females, mean age 75 ± 8.3 years) were finally included for analysis. Median follow-up for the cohort was 27 (interquartile range 12-48) months. A median 6 (interquartile range 3) EndoAnchors were deployed at ESAR, 175 (79%) procedures were primary and 46 (21%) revision cases, 40 associated with type IaEL. Technical success at operation (initial), 30-day, and overall success were 89, 95.5, and 96.8%, respectively; the 30-day success was higher due to those with subsequent spontaneous proximal endoleak seal. At two years, freedom from type IaEL was 94% for the whole series; 96% and 86% for the primary and revision groups, respectively; whereas freedom from all-cause mortality, aneurysm-related mortality, and reintervention was 89%, 98%, and 87%, respectively. Sac evolution pre-ESAR was 66 ± 15.1 vs. post ESAR 61 ± 17.5 (p < 0.001) and for 180 patients with at least six-month follow-up, 92.2% of them being in a stable (51%) or regression (41%) situation. CONCLUSIONS: This real-world registry demonstrates that adjunct EndoAnchor usage at EVAR achieves high rates of freedom from type IaEL at mid-term including in a high number of patients with hostile neck anatomy, with positive trends in sac-size evolution. Further data with longer follow-up may help to establish EndoAnchor usage as a routine adjunct to EVAR, especially in hostile necks.

Carotid artery stenosis in correlation with neck and carotid artery anatomy.

OBJECTIVES: The purpose of this study was to examine the relationship between neck anatomy, especially its largest muscle - sternocleidomastoid and carotid space, with carotid artery anatomy and stenosis. METHODS: We analysed 102 computed tomography carotid angiograms. The study included the measurement of the neck and sternocleidomastoid length, diameter and volume and the size of the carotid space. Analysis of carotid artery geometry, the length, angle and height of carotid artery bifurcation and the direction of the internal carotid artery origin was also included. RESULTS: We found a positive correlation only between the neck and carotid length. There was no correlation between other neck characteristics and a carotid anatomy or internal carotid artery stenosis. Direction of internal carotid artery origin was significantly different (p < 0.01) between the left and right sides. CONCLUSIONS: We have not found a correlation between the size of sternocleidomastoid and carotid space and carotid stenosis as a hypothetical factor for atherosclerosis. Also, the degree of carotid artery stenosis did not correlate with other neck and carotid measurements. Neck and carotid anatomy correlated only in their lengths. The left internal carotid artery showed mostly posterolateral origin, and right internal carotid artery had no predominate direction.

Comparative clinical study of short-term outcomes between table fenestrated and chimney endovascular aneurysm repair for hostile neck aneurysms.

OBJECTIVES: Hostile neck abdominal aortic aneurysm (AAA) is challenging for standard endovascular aneurysm repair (EVAR). We sought to compare fenestrated endovascular aneurysm repair (fEVAR) and chimney endovascular aneurysm repair (chEVAR) for hostile neck AAA. METHODS: Patients were identified retrospectively. Hostile neck anatomy was defined as a proximal neck length of <15 mm or angulation >60°. The choice of fEVAR or chEVAR was based on neck anatomy and physician preference. Type I endoleak (T1EL) was the primary outcome. Other outcomes included type III endoleak (T3EL), visceral stent occlusion, renal insufficiency, reintervention, and mortality. RESULTS: A total of 84 patients were included from April 2012 to December 2021. fEVAR and chEVAR patients were 48 and 36 cases, respectively. Both groups showed similar rate of T1EL, T3EL, visceral stent occlusion, renal insufficiency, reintervention, and mortality. However, chEVAR patients had a more tortuous neck (61.1% vs. 16.7%, p < 0.001), while fEVAR patients had a greater neck size (29.5 ± 6.3 mm vs. 24.5 ± 4.8 mm, p < 0.001) and more reconstructing target arteries (2.2 ± 1.1 vs 1.3 ± 0.6, p < 0.001). CONCLUSIONS: fEVAR and chEVAR show similar safe and effective outcomes in well-selected hostile neck. fEVAR might be able to reconstruct multiple visceral arteries, and chEVAR seems justified in patients with poor anatomical suitability for fEVAR.

A preliminary investigation of digital media supplements for head and neck anatomy: Does production format matter?

From cassettes to digital, use of video in education has evolved. Supplemental digital media is a common educational adjunct within gross anatomy courses. As these aids have advanced technologically, so has production cost. Traditional lecture (T-lect) productions tend to be more efficient. Traditional gross anatomy laboratory (T-lab) productions requiring cadaver dissection and high-definition video are comparatively less efficient. This preliminary study pragmatically assessed T-lect and T-lab supplemental learning tools in a head and neck anatomy course for first-year dental students. Two videos of similar length were developed for different anatomical regions. Learning objectives were similar while format differed. A carotid triangle supplement was created using a T-lab production format and an infratemporal fossa aid was created using a T-lect format. Both incorporated recommended elements for facilitating learning. Development time and costs were documented. Student exam performance on topic specific questions was collected along with survey data. Group mean exam score comparisons between students who viewed (n = 74 T-lect, n = 70 T-lab) versus did not view (n = 27 T-lect, n = 30 T-lab) each aid revealed higher scores for the "viewed" group. The T-lab production cost ($15,190 versus $10,003) and time (19 hr. versus 18 hr) were greater than T-lect. Descriptive survey data did not reveal a format preference. Students valued previews/summaries and structure highlighting/labeling within the supplements. Students appreciated the supplemental learning aids and mean exam scores were higher for users. Since production format did not noticeably alter exam performance and satisfaction was similar, production efficiency should take precedence.

The devil is in the details: developing a modern methodology for detailed medical illustrations.

The Pernkopf Atlas has posed an ethical dilemma for the past 30 years. Although its illustrations are of an indisputably high quality, its unethical origins yield questions with its use. This study aimed to identify successful methods for creating equal if not higher quality anatomical visualisations through an analysis and comparison of past and present medical illustrator's techniques. Pernkopf's illustrations were not used as an anatomical reference to ensure the new visuals were ethical; instead other existing visuals and written sources were compiled and reviewed to create an original 3D model of the posterior cervical triangle using ZBrush 2020. Some visualisation techniques used by Pernkopf were used as a part of this project (i.e. rendering in partial colour) this technique is not unique to Pernkopf and was also used by Henry Carter, the illustrator of Grey's anatomy. The survey was distributed to 78 participants with a strong anatomical or medical/biological art background. The reception to the new resource was positive; participants favoured it in terms of quality and ease of understanding. However, participants noted that the images in the survey were not the same resolution which may have skewed the results in favour of the new image. When rated for detail compared to the Pernkopf Atlas, the number of structures in the resource need to be increased before it can be ranked equally to the Pernkopf Atlas for detail. Participants did note that they may have selected differently depending on what was inferred by quality and detail in the survey.

The intercarotid or alar fascia, other cervical fascias, and their adjacent spaces - a plea for clarification of cervical fascia and spaces terminology.

Due to varying descriptions and terminology of fascias of the neck, medical advice relying on this basic knowledge is insufficient. Our goal was to provide a precise anatomical description of cervical fascias and spaces with special focus on the intercarotid fascia, or the alar fascia. One hundred bodies donated to science embalmed with Thiel's method were investigated, cervical fascias were dissected layer by layer, and the results were documented by photography, with a focus on the intercarotid fascia. In addition, we performed a review of recent literature concerning cervical surgical interventions, radiological diagnostic pathways, and basic anatomical works focusing on core information on anatomical relations of cervical fascias and spaces. In another 10 bodies donated to science, the spaces of the neck were injected with coloured latex under ultrasound guidance, dissected, and documented by photography. The intercarotid fascia was a constantly developed connective tissue interconnecting the carotid sheath of both sides. In 52 of 100 specimens (52%) it crossed to the opposite side without any fusion to the ventrally situated visceral fascia. Fusion with the visceral fascia was found in 48%, either at the lateral border of the pharynx or on its dorsal side. The results of our dissections strengthen the precise description of the cervical fascias provided by Grodinsky and Holyoke in 1938. Spaces can be confirmed as described by Hafferl in 1969. The international anatomical and ENT societies should codify a unified anatomical terminology of the cervical spaces and fascias to prevent varying interpretations in the future.

Development of a template tool for facilitating fibula osteotomy in reconstruction of mandibular defects by digital analysis of the human mandible.

OBJECTIVES: Mandibular reconstruction after segmental mandibulectomy can be challenging without virtual surgical planning and osteotomy guides. The purpose of this study was to analyze anatomic parameters to facilitate the evaluation of ideal fibula wedge osteotomies to reconstruct the neomandibula in a simple and cost-effective manner without the need for preoperative virtual planning. MATERIALS AND METHODS: Computed tomography scans were acquired from randomly selected patients, and all images were obtained from routine clinical diagnostics, e.g., tumor staging, or preoperatively before reconstruction. Data was used to calculate stereolithographic models of the mandible for length and angle measurements. Statistical analysis was performed (p < 0.05). RESULTS: CT scans of 100 patients were analyzed: 39 were female and 61 were male patients, mean age was 59.08a. The mandibular arch angle proved to be constant with 241.07 ± 2.39°. The outside B-segment length was 80.05 ± 5.16 mm; the anterior S-segment length was 27.69 ± 3.16 mm. The angle of the mandibular arch showed differences in means (p = 0.004) between age groups, but effect was proved low. No relevant statistical significances were detected. CONCLUSIONS: The development of a mandible reconstruction template tool would benefit the majority of head and neck patients, which is due to a constant mandibular arch angle and symphysis segment length throughout the general patient population, allowing the mimicking of a harmonic mandibular arch with up to three fibula segments. CLINICAL RELEVANCE: The developed mandible reconstruction template tool can facilitate the fibula wedge osteotomies necessary for reconstruction of an ideal neomandibula providing a novel approach which is simple and cost-effective.

[Proximal fixation devices in endovascular repair of abdominal aortic aneyrysm with unfavourable proximal neck anatomy]. / Ustroistva proksimal'noi fiksatsii stent-grafta pri éndovaskuliarnom lechenii anevrizmy briushnogo otdela aorty s neblagopriiatnoi anatomiei proksimal'noi sheiki.

Abdominal aortic aneurysm is a common vascular disease requiring surgical treatment. Currently, endovascular aortic repair is a good alternative to open surgery. However, high incidence of unfavorable anatomical variants of the proximal landing zone limit the use of endovascular aortic repair in these patients. Additional techniques can increase applicability of endovascular procedure with optimal results. Two patients with unfavorable proximal neck anatomy undergoing endovascular aortic repair with anchor type of proximal fixation devices are reported in the article.

The Long-term Durability of Intra-operatively Placed Palmaz Stents for the Treatment of Type Ia Endoleaks After EVAR of Abdominal Aortic Aneurysm.

OBJECTIVE/BACKGROUND: The objective was to analyze the long-term durability of intra-operatively placed Palmaz stents for type Ia endoleaks, and the evolution of aneurysm neck morphology. METHODS: This was a retrospective cohort study conducted at a tertiary referral centre. Patients treated between 1998 and 2012 were reviewed with regard to pre-, intra-, and post-operative data. Crude and relative survival estimates were calculated, with the latter referring only to patients with ≥ 3 months' follow-up. RESULTS: In total, 125 patients were included (83 elective, 22 ruptures, 20 symptomatic). Nine patients died perioperatively (two elective, seven acute). Median follow-up was 43 months (range 15-72). Seven patients had late abdominal aortic aneurysm related deaths. There were 51 re-interventions (seven type Ia endoleak related). Five year crude primary, primary assisted, and secondary success rates were 55 ± 5%, 66 ± 5%, and 70 ± 5%, respectively. These crude rates were superior for elective patients (p = .008, p = .031, and p = .037, respectively), but the relative rates were not (p = .187, p = .640, p = .558, respectively). Primary and assisted freedom from type Ia endoleak 5 years post-operatively were 84 ± 4% and 89 ± 3%, respectively. These rates were superior in elective patients (p = .066 and p = .145, respectively), especially when relative rates were analysed (p = .025 and p = .063, respectively). The visceral aortic diameter increased significantly between the first and the last post-operative imaging in 15/91 (16%), 12/91 (13%), 34/91 (37%), and 30/91 (33%) patients at the levels of coeliac trunk, superior mesenteric artery, lowest renal artery, and 9 mm distal to lowest renal artery, respectively. CONCLUSION: Intra-operatively placed Palmaz stents confer high long-term freedom from type Ia endoleak. Palmaz stents are an acceptable intra-operative bailout tool in the acute setting, but should not be used to extend elective infrarenal endovascular aneurysm repair to more demanding anatomies.

Impact of the Repositionable C3 Excluder System on the Endovascular Treatment of Abdominal Aortic Aneurysms With Unfavorable Neck Anatomy.

PURPOSE: To analyze the midterm clinical outcomes among patients with favorable and unfavorable neck morphology for endovascular aneurysm repair (EVAR), specifically the impact of the repositionable C3 Excluder stent-graft on type I endoleak in patients with unfavorable neck. METHODS: A retrospective review was conducted of 249 patients (mean age 74.3 years; 241 men) who underwent successful EVAR from January 2000 to December 2014 using either the traditional Excluder (n=140) or the C3 repositionable system (n=109). Unfavorable proximal aortic neck anatomy was defined by length <15 mm, angulation >60°, >50% circumferential thrombus, or >50% neck calcification. By these criteria, unfavorable neck anatomy was present in 71 (28.5%) patients (41 traditional Excluder and 30 C3 Excluder). The main endpoint was the incidence of type Ia endoleak and the need for a proximal cuff according to the type of neck anatomy. Comparisons between groups are reported as the odds ratio (OR) and 95% confidence interval (CI). RESULTS: A proximal extension cuff for type Ia endoleak was needed in 4 (2.2%) patients with favorable neck anatomy compared to 7 (9.9%) patients with unfavorable neck (OR 4.76, 95% CI 1.3 to 16.8, p=0.014). Among the patients with unfavorable neck, a proximal cuff was implanted in 6/41 (14.6%) traditional Excluder stent-grafts vs 1/30 (3.3%) in the C3 Excluder group (OR 4.39, 95% CI 0.55 to 34.58, p=0.23). Median follow-up was 30.5 and 38 months for favorable vs unfavorable neck groups, respectively (p=0.29). Only 1 case of type Ia endoleak was registered at 6.5 years' follow-up (traditional Excluder), with no device migration. CONCLUSION: Both Excluder stent-grafts provide good midterm clinical outcomes after EVAR in patients with unfavorable neck anatomy. Investigation of a larger cohort will be needed to identify if the C3 Excluder device offers any improvement over the traditional Excluder in terms of freedom from endoleaks.

Atypical location of the hypoglossal nerve and its implications: a case report.

INTRODUCTION: Successful surgery in the neck is dependent on reliable anatomical relationships between nerves, vessels, and muscles. These landmarks and planes are also essential to avoiding undue morbidity and mortality. Anatomic variants of the hypoglossal nerve are rare, and their incidences are unknown. METHODS: We describe a case of a hypoglossal nerve found coursing superficial to the internal jugular vein in a 52-year-old woman treated with bilateral selective neck dissection for metastatic thyroid malignancy. RESULTS: The vulnerable nerve was protected, and she maintained excellent speech and swallow function post-operatively. CONCLUSIONS: The variant course of the nerve may pose higher risk for injury in neck surgery. Surgeons should be aware of the possibility of aberrant anatomy in this region and exercise extra caution to avoid nerve injury.

Extracranial internal carotid artery: anatomical variations in asymptomatic patients.

The anatomical variations of internal carotid artery (ICA) are mostly asymptomatic, thus being disregarded and only incidentally diagnosed, with very few symptomatic patients. The awareness of these anomalies is crucial to solve the differential with other neck lesions, preventing accidental injuries during neck surgery. Therefore, the aim of our study is to estimate the prevalence of ICA anomalies, using magnetic resonance angiography (MRA) and computed tomography angiography (CTA). 253 patients underwent head and neck MRA and CTA examinations, with multiplanar and volumetric reformations. For each set of images, the following items were investigated: origin, development, course, persistence of embryonic vessels and anomalous origin of collateral branches. In our series, ICA arose from the bifurcation of the common carotid artery at the level of: C4 in 303 hemi-necks (59.9 %); C3 in 98 hemi-necks (19.3 %); C5 in 57 hemi-necks (11.3 %); C2 in 48 hemi-necks (9.5 %). ICA kinking and/or coiling was found in 105 hemi-necks, and location variation of ICA (reversed-type) in two hemi-necks. In just one case the origin of the ascending pharyngeal artery was from ICA (0.2 %), while an anomalous persistence of the proatlantal artery was noticed in three cases (0.6 %). CTA and MRA showed similar accuracy in detecting ICA anomalies.

Ultrasonographic measurements of the omohyoid muscle during shoulder muscles contraction.

BACKGROUND: The main function of the omohyoid muscle is to depress and withdraw the hyoid bone. This is an integral part of the swallowing process facilitating hyoid stabilization for tongue movement. Although the muscle is inferiorly attached to the scapula bone, its function during shoulder or scapula muscles contraction has yet not been studied. AIM: To investigate whether changes occur in omohyoid muscle morphology during shoulder muscles contraction. METHODS: The study included 40 healthy subjects (20 males and 20 females, Mean age: 25.68 (± 2.90) years) examined via diagnostic ultrasound. Omohyoid muscle morphology measurements (thickness and cross-sectional area) during different shoulder position (0°, 90° abduction and elevation) in rest and during isomteric contraction were evaluated. RESULTS: The omohyoid muscle was activated when the shoulder was isometrically abducted at 90° abduction. Thickness and the cross-sectional area of the lower belly increased during contractions at 90° abduction compared with a resting position at 90° (p value < 0.01). No changes occurred at 0° isometric abduction. The CSA of the muscle was found to be significantly larger (p < 0.001) during contraction at 90° abduction compared with contraction at 0° abduction. CONCLUSION: Omohyoid muscle was most contracted during abduction position with abduction shoulder muscles isometric contraction. Changes of the scapula position might influence omohyoid muscle function.

Aligning Orifice of the Renal Artery with Fish-Mouth FIXation Technique During Endovascular Aortic Aneurysm Repair for Hostile Neck Anatomy.

Background: As the success of endovascular aortic aneurysm repair (EVAR) depends on sufficient proximal fixation of the endograft to the aortic wall, the proximal hostile neck anatomy (HNA) is the major potential treatment-limiting factor in EVAR. The Aorfix endovascular stent graft was designed to operate on highly angulated aortic necks. The Aligning Orifice of the Renal artery with fish-mouth FIXation (AORFIX) technique uniquely and accurately aligns the trough part of the proximal stent end with the orifice of the lower renal artery and is used to optimize the proximal fish-mouth design for maximum proximal seal use. Herein, we aimed to evaluate the usefulness of the AORFIX technique for EVAR in patients with HNA. Methods: Eighty-one consecutive patients who underwent EVAR with the AORFIX technique (+AORFIX technique group, n = 16) and without (standard group, n = 65) were evaluated. The HNA was defined as any of the following: neck angulation ≥60°, neck length ≤15 mm, or neck thrombus or calcification ≥50% of the circumference and conical neck. Results: Each HNA criterion was similar between the two groups. However, the average number of HNA criteria was significantly higher in the +AORFIX technique group (1.9 ± .2 vs. 1.3 ± .1; P < .01). The two groups showed 100% procedural success. The concurrent renal angioplasty and stenting rates (88% vs. 4.6%; P < .01) were significantly higher in the +AORFIX technique group. There were no 30-day deaths in either group and no in-hospital device-related events in the +AORFIX technique group. The median follow-up period was 39 months, and there was no significant between-group difference in freedom from reintervention rate (+AORFIX group vs. standard group, 100% vs. 91.0%; P = .327). Conclusion: EVAR using the AORFIX technique might be useful even in patients with more complex HNA.

Student learning of head and neck anatomy using cone beam computed tomography and immersive virtual reality.

OBJECTIVES: The purpose of this study was to evaluate the efficacy of student learning of anatomy and 3D imaging concepts using cone beam computed tomography (CBCT) and immersive virtual reality (VR) technology. METHODOLOGY: Ninety (n = 90) first year dental students with no previous experience in 3D imaging were recruited. All participants completed a 10-item, multiple-choice questionnaire (MCQ) and a pre-survey prior to the educational intervention. Following a brief video orientation on CBCT and anatomy, each participant underwent a one-on-one educational intervention using immersive VR with calibrated instructors to identify head and neck anatomic structures using a VR/CBCT educational tool. Immediately following the intervention, all participants completed a postsurvey, a second MCQ, NASA task load index and presence questionnaires. Participants completed a third MCQ 2 weeks following the intervention. Analysis of objective measures of performance on MCQ's (p < 0.05) and subjective data from the questionnaires was completed. RESULTS: The students doubled their mean test scores 2.45 ± 1.274 to 5.99 ± 1.576 on MCQ's immediately following the educational intervention (p < 0.05). The significant increase in the MCQ test scores was maintained after 2 weeks, 5.73 ± 1.721 (p < 0.05). There were no gender differences in student test performance. Students rated the immersive VR/CBCT educational intervention experience highly for control, sensory, and realism factors with minimal distraction and frustration factors. CONCLUSION: Results from this study show that immersive VR/CBCT educational intervention improved test performance and contributed to information recall in students. Further benefits reported by participants include the sense of presence and increased engagement using immersive VR.

Optimal anatomical angle and distance for drilling in cervical oblique corpectomy: A surgical anatomical study.

Background: One of the difficulties of oblique corpectomy, less discussed in the literature, is the problem of how to achieve an optimum corpectomy. Therefore, this anatomico-radiological study was conducted to shed light on the use of the microscope at an appropriate angle and optimum drill distances in clinical cases undergoing cervical oblique corpectomy surgery. Materials and Methods: We examined the average distance of the diagonal line extending from the medial aspect of the ipsilateral vertebral foramen to the contralateral pedicle in cervical computed tomography -angiography axial scans in four cervical vertebrae, C3, C4, C5, and C6. We also measured the average angle between this diagonal trajectory and the horizontal line, making a total of 712 measurements in 89 patients. Results: We found that horizontal drilling with an average length of 23-26 mm at an acute angle of about 22° -23° is optimal for adequate decompression of the spinal cord in the oblique corpectomy approach. Depending on the patient and the level of the vertebra, the distance and the angle of the horizontal drilling may range from 18 mm to 31 mm and from 15° to 33°, respectively. Conclusions: For an optimum cervical oblique corpectomy that provides adequate spinal cord decompression and maintains spinal stability, it is necessary to operate under a surgical microscope positioned at an acute angle and to know the horizontal drilling distance.