RESUMEN
Reconstruction of large soft tissue foot defects were considered a difficult issue due to weight-bearing function of the foot. The reconstruction becomes more difficult when both plantar and dorsal soft tissues are involved. The options for the reconstruction were variable, in 2016 Hao Wu etâ al. presented a combined flap for coverage of combined fore-foot plantar and dorsal soft tissue defects. We used combined flaps in two cases and present our experience in this article.
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Procedimientos de Cirugía Plástica , Humanos , Masculino , Procedimientos de Cirugía Plástica/métodos , Arterias Tibiales/cirugía , Colgajos Tisulares Libres/trasplante , Persona de Mediana Edad , Femenino , Pie/cirugía , Traumatismos de los Pies/cirugía , Traumatismos de los Tejidos Blandos/cirugía , Adulto , Colgajos QuirúrgicosRESUMEN
BACKGROUND: Structural changes in the lower limb's arterial wall in amateur endurance runners are a rare incidental finding, represented just by several case reports. AIM: Study the incidence of non-atherosclerotic lower limb artery wall changes in defined group of amateur endurance runners and identify relationship with the training parameters and the relevant biochemical markers. METHODS: Amateur male athletes engaged in endurance running for more than 5 years were enrolled. Tibial and anterior popliteal arteries on each side were examined by ultrasound with focus on non-atherosclerotic structural wall changes: intima-medial border blurring, presence and character of non-atherosclerotic noduli. Subsequently the descriptive and correlation analysis were performed. RESULTS: The study enrolled 20 amateur male endurance runners from Black Swan Triathlon Club Slovakia. The low atherosclerotic risk was represented by normal lipid levels, BMI under 30 kg/m2 and non-smokers in all participants. At least one type of structural artery wall abnormality (noduli or intima-medial border blurring) was present in 19 of 20 participants (95%). The most present was the intima-medial blurring. (80% of participants). The noduli were present in 65% of study group, in almost 40% of these, they were considered as hyperechogenic. All these affections were predominantly in popliteal artery area (65%). The vast majority has bilateral affection. We find a mild correlation between these ultrasound findings and training load represented by annual kilometers and run hours. There was no association between these changes and lipid spectrum or CRP level. CONCLUSION: The subclinical lower limb artery changes, represented by intima-medial border blurring and non-atherosclerotic noduli were present in almost every amateur endurance runner. Despite the underlying mechanism is not understood, the increased training load seems to be one of the responsible factors.
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Carrera , Túnica Íntima , Ultrasonografía , Humanos , Masculino , Carrera/fisiología , Adulto , Ultrasonografía/métodos , Túnica Íntima/diagnóstico por imagen , Resistencia Física , Extremidad Inferior/irrigación sanguínea , Extremidad Inferior/diagnóstico por imagen , Arteria Poplítea/diagnóstico por imagen , Atletas , Persona de Mediana Edad , Arterias Tibiales/diagnóstico por imagen , Túnica Media/diagnóstico por imagenRESUMEN
BACKGROUND: There is a paucity of data evaluating outcomes of lower extremity bypass (LEB) using supra-inguinal inflow for revascularization of infra-inguinal vessels. The purpose of this study is to report outcomes after LEB originating from aortoiliac arteries to infra-femoral targets. METHODS: The Vascular Quality Initiative database (2003-2020) was queried for patients undergoing LEB from the aortoiliac arteries to the popliteal and tibial arteries. Patients were stratified into 3 cohorts based on outflow targets (above-knee [AK] popliteal, below-knee [BK] popliteal, and tibial arteries). Perioperative and 1-year outcomes including primary patency, amputation-free survival (AFS), and major adverse limb events (MALEs) were compared. A Cox proportional hazards model was used to estimate the independent prognostic factors of outcomes. RESULTS: Of 403 LEBs, 389 (96.5%) originated from the external iliac artery, while the remaining used the aorta or common iliac artery as inflow. In terms of the distal target, the AK popliteal was used in 116 (28.8%), the BK popliteal in 151 (27.5%), and tibial vessels in 136 (43.7%) cases. BK popliteal and tibial bypasses, compared to AK popliteal bypasses, were more commonly performed in patients with chronic limb-threatening ischemia (69.5% and 69.9% vs. 48.3%; P < 0.001). Vein conduit was more often used for tibial bypass than for AK and BK popliteal bypasses (46.3% vs. 21.9% and 16.3%; P < 0.001). In the perioperative period, BK popliteal and tibial bypass patients had higher reoperation rates (16.9% and 13.2% vs. 5.2%; P = 0.02) and lower primary patency (89.4% and 89% vs. 95.7%; P = 0.04) than AK bypass patients. At 1 year, compared with AK popliteal bypasses, BK and tibial bypasses demonstrated lower primary patency (81.9% vs. 56.7% vs. 52.4%, P < 0.001) and freedom from MALE (77.6% vs. 70.2% vs. 63.1%, P = 0.04), although AFS was not significantly different (89.7% vs. 90.6% vs. 83.8%, P = 0.19).On multivariable analysis, compared with AK popliteal bypasses, tibial bypasses were independently associated with increased loss of primary patency (hazard ratio 1.9, 95% confidence interval, 1.03-3.51, P = 0.04). Subanalysis of patients with chronic limb-threatening ischemia demonstrated significantly higher primary patency in the AK popliteal cohort at discharge and 1 year, but no difference in AFS or freedom from MALE between the cohorts at follow-up. CONCLUSIONS: LEB with supra-inguinal inflow appear to have acceptable rates of 1-year patency and limb salvage in patients at high risk of bypass failure. Tibial outflow target was independently associated with worse primary patency but not with MALE or AFS.
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Amputación Quirúrgica , Bases de Datos Factuales , Recuperación del Miembro , Enfermedad Arterial Periférica , Grado de Desobstrucción Vascular , Humanos , Masculino , Anciano , Femenino , Estudios Retrospectivos , Enfermedad Arterial Periférica/fisiopatología , Enfermedad Arterial Periférica/cirugía , Enfermedad Arterial Periférica/diagnóstico por imagen , Factores de Tiempo , Factores de Riesgo , Persona de Mediana Edad , Medición de Riesgo , Arteria Poplítea/cirugía , Arteria Poplítea/fisiopatología , Arteria Poplítea/diagnóstico por imagen , Injerto Vascular/efectos adversos , Supervivencia sin Progresión , Arteria Ilíaca/cirugía , Arteria Ilíaca/fisiopatología , Arteria Ilíaca/diagnóstico por imagen , Flujo Sanguíneo Regional , Arterias Tibiales/fisiopatología , Arterias Tibiales/cirugía , Arterias Tibiales/diagnóstico por imagen , Extremidad Inferior/irrigación sanguínea , Resultado del Tratamiento , Anciano de 80 o más AñosRESUMEN
During tibial plateau leveling osteotomy (TPLO), the laceration of the cranial tibial artery (LCTA) may occur, and the ligation of the cranial tibial artery might lead to impaired blood supply to the osteotomy site. The present case-control study aimed to evaluate the effect of LCTA on TPLO healing and the occurrence of perioperative complications. The incidence and predisposing factors to LCTA were also investigated. Fourteen cases experiencing LCTA were retrospectively enrolled from medical records of two veterinary teaching hospitals (LCTA group), whereas 28 randomly selected TPLOs that did not experience LCTA were included in the control group. Signalment data, proximal tibial epiphysis conformation, osteotomy features, perioperative complications, and bone healing were compared between the two groups. Bone healing was evaluated using the modified radiographic union scale for tibial fracture and the visual analog scale. The mean incidence was 9.6%. Bodyweight was significantly higher in the LCTA group compared to the control group (P = 0.009). Dogs belonging to the LCTA groups were significantly younger (P = 0.01). Intraoperative hypotension was significantly overreported in the LCTA group (P = 0.0001). None of the other variables differed significantly between the two groups. Dogs' size seems to be a predisposing factor, with dogs weighing >15 kg having 22 times more chance of experiencing LCTA. Due to the well-developed collateral blood supply of the canine hindlimb, LCTA and the closure of the cranial tibial artery did not appear to delay the radiographic bone healing or affect the incidence of perioperative complications.
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Osteotomía , Tibia , Arterias Tibiales , Animales , Perros , Osteotomía/veterinaria , Femenino , Masculino , Estudios de Casos y Controles , Estudios Retrospectivos , Tibia/cirugía , Tibia/irrigación sanguínea , Arterias Tibiales/diagnóstico por imagen , Arterias Tibiales/lesiones , Arterias Tibiales/cirugía , Complicaciones Posoperatorias/veterinaria , Complicaciones Posoperatorias/etiología , Enfermedades de los Perros/cirugía , Enfermedades de los Perros/diagnóstico por imagen , Curación de Fractura , Laceraciones/veterinaria , Laceraciones/cirugíaRESUMEN
The uncertainty concerning the physiological effects of compression bandaging on the peripheral blood flow is a challenge for healthcare professionals. The main objective was to determine the haemodynamic impact on the distal posterior tibial artery after the application of a high-compression leg multicomponent bandaging system using 4D flow magnetic resonance imaging. Leg dominance disparities of the posterior tibial artery before and after the application of the compressive bandage were also analysed. Twenty-eight healthy female volunteers were recruited (mean: 25.71, standard deviation: 4.74 years old) through a non-probability convenience sampling. The 4D flow magnetic resonance imaging of the distal tibial posterior artery was performed in all participants, first under standard resting conditions and after the application of a compression bandage in the leg. When the strong compressive bandage was applied, the area of the assessed artery decreased by 14.2%, whilst the average speed increased by 19.6% and the flow rate increased by 184.8%. There were differences between the haemodynamic parameters of both legs according to dominance, being statistically significantly lower in the dominant leg. The application of strong compressive bandaging significantly increases the arterial flow and mean velocity in the distal segment of the posterior tibial artery, in healthy volunteers by 4D flow magnetic resonance imaging. In this study, leg dominance influenced some of the haemodynamic parameters. According to the results, leg compression bandages cannot be contraindicated in vascular ulcers with arterial compromise.
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Vendajes de Compresión , Hemodinámica , Imagen por Resonancia Magnética , Arterias Tibiales , Humanos , Femenino , Arterias Tibiales/diagnóstico por imagen , Arterias Tibiales/fisiopatología , Adulto , Imagen por Resonancia Magnética/métodos , Hemodinámica/fisiología , Adulto Joven , Voluntarios Sanos , Pierna/irrigación sanguíneaRESUMEN
The medial plantar artery flap (MPAF) presents both unique value as well as significant challenges. As the plantar foot has specific anatomy, the use of the MPAF to recreate this highly specialized area may provide improvements in durability and rates of limb salvage. The purpose of this study is to establish the anatomic course of the branching patterns of the medial plantar artery (MPA) and provide a foundation for MPA flap nomenclature as it is related to design and elevation. Thirty-seven fresh frozen cadaver feet were used for dissection: 20 right and 17 left sided limbs. Anatomic measurements recorded included: branching pattern of the MPA, bifurcation distance of the superficial branch (SB) and deep branch (DB) from the origin of the MPA, distance from the MPA origin to the anterior colliculus of the medial malleolus, and the distance from the SB and the DB to the navicular tuberosity. The MPA was found to bifurcate into SB and DB in 30 (81%) specimens; 6 (16%) specimens had only a SB, whereas 1 (3%) specimen had only a DB, which had not been previously described. The distance from the anterior colliculus to the MPA was 3.0 cm, MPA to the distal bifurcation was 2.9 cm, and navicular tuberosity to the SB and DB was 2.2 cm and 1.3 cm, respectively. Minimizing the complexity of the dissection with the use of more reliable landmarks and a deeper understanding of the anatomy may reduce complications and allow for more reproducible outcomes when utilizing the MPAF.
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Cadáver , Pie , Colgajos Quirúrgicos , Humanos , Pie/anatomía & histología , Pie/irrigación sanguínea , Colgajos Quirúrgicos/irrigación sanguínea , Masculino , Femenino , Arterias Tibiales/anatomía & histología , Disección , AncianoRESUMEN
BACKGROUND: Infra-popliteal interventions for chronic limb-threatening ischemia (CLTI) can be impacted by the morphology of the tibial vessels. The aim of this study was to examine the impact of a novel morphology-driven classification on the outcomes of isolated tibial intervention for CLTI. METHODS: A database of patients undergoing isolated tibial interventions for CLTI at a single center between 2010 and 2020 was retrospectively queried. Patients with isolated infra-popliteal disease were identified, and their anatomy was scored as present or absent for lesion calcification (1 point), target vessel diameter<3.0 mm (1 point), lesion length>300 mm (1 point), and poor pedal runoff score (1 point). Patients were then divided into 3 groups: low risk (0 or 1 points), moderate risk (2 points), and high risk (3 or 4 points). Intention to treat analysis by the patient was performed. Limb-based patency (the absence of reintervention, occlusion, critical stenosis [>70%], or hemodynamic compromise with ongoing symptoms of CLTI as it related to the patency of the preoperatively determined target artery pathway) was assessed. Patient-oriented outcomes of amputation-free survival (AFS; survival without major amputation) and freedom from major adverse limb events (MALE; above ankle amputation of the index limb or major reintervention: new bypass graft, jump/interposition graft revision) were evaluated. RESULTS: 1,607 patients (55% male, average age 60 years, 3,846 vessels) underwent tibial intervention for CLTI. The majority of the patients were diabetic and of Hispanic origin. Morphologically, 27%, 31%, and 42% of the vessels were categorized as low risk, moderate risk, and high risk, respectively. There was a significant worsening of the infra-popliteal Global Limb Anatomic Staging System (GLASS) grading as the morphological risk increased. The 30-day major adverse cardiac events (MACE) were equivalent across the groups and were under the stated objective performance goal (OPG) of ≤10%. In contrast, both the 30-day MALE and the 30-day major amputations were significantly different across the groups, with the low-risk group remaining under the OPG of ≤9% and ≤4%, respectively, while the moderate risk and high risk exceeded the goal threshold. For the OPG, freedom from MALE was 60 ± 5%, 46 ± 5%, and 22 ± 9% at 5 years for low-, moderate-, and high-risk groups, respectively (mean ± standard error of the mean; P = 0.008). Overall AFS was 55 ± 5%, 37 ± 6%, and 18 ± 7% at 5 years for low-, moderate-, and high-risk groups, respectively (mean ± standard error of the mean; P = 0.003). CONCLUSIONS: Tibial anatomic morphology impacts isolated tibial endovascular intervention with adverse morphology associated with poorer short- and long-term outcomes. Risk stratification based on anatomic predictors should be an additional consideration as one intervenes on infra-popliteal vessels for CLTI.
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Amputación Quirúrgica , Isquemia Crónica que Amenaza las Extremidades , Bases de Datos Factuales , Recuperación del Miembro , Enfermedad Arterial Periférica , Arterias Tibiales , Grado de Desobstrucción Vascular , Humanos , Masculino , Estudios Retrospectivos , Femenino , Anciano , Factores de Riesgo , Enfermedad Arterial Periférica/fisiopatología , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/terapia , Enfermedad Arterial Periférica/cirugía , Arterias Tibiales/fisiopatología , Arterias Tibiales/diagnóstico por imagen , Arterias Tibiales/cirugía , Factores de Tiempo , Persona de Mediana Edad , Medición de Riesgo , Isquemia Crónica que Amenaza las Extremidades/cirugía , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Supervivencia sin Progresión , Anciano de 80 o más Años , Resultado del Tratamiento , Isquemia/fisiopatología , Isquemia/cirugía , Isquemia/diagnóstico por imagen , Isquemia/terapiaRESUMEN
Retrograde tibio-pedal access represents a feasible method for endovascular revascularization when antegrade methods fail. The article offers an extensive review of retrograde tibio-pedal access, emphasizing the technique and documented outcomes.
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Procedimientos Endovasculares , Enfermedad Arterial Periférica , Humanos , Enfermedad Arterial Periférica/terapia , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/fisiopatología , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/efectos adversos , Resultado del Tratamiento , Arterias Tibiales/diagnóstico por imagen , Arterias Tibiales/cirugía , Arterias Tibiales/fisiopatología , Punciones , Factores de Riesgo , Cateterismo Periférico/efectos adversosRESUMEN
BACKGROUND: Ethylene diamine tetra-acetic acid (EDTA) is a chelating agent used to dissolve calcium deposits but evidence in decalcifying atherosclerotic lesions is limited. AIMS: We assessed the feasibility and efficacy of EDTA delivered via porous balloon to target calcified lesions in cadaveric below-the-knee (BTK) arteries. METHODS: Using porcine carotid arteries, EDTA concentration was measured in the arterial wall and outside the artery at the 0-, 0.5-, 4-, and 24-h circulation after the injection through a porous balloon. In cadaver BTK samples, the proximal and distal anterior tibial artery (ATA) and distal posterior tibial artery (PTA) were studied. EDTA-2Na/H2O or EDTA-3Na/H2O were administrated using a porous balloon, then circulated for 6 h for EDTA-3Na/H2O and 24 h for EDTA-2Na/H2O and EDTA-3Na/H2O. Micro-CT imaging of the artery segments before and after the circulation and cross-sectional analyses were performed to evaluate calcium burden. RESULTS: In the porcine carotid study, EDTA was delivered through a porous balloon present in the arterial wall and was retained there for 24 h. In BTK arteries, cross-sectional analyses of micro-CT revealed a significant decrease in the calcium area in the distal ATA segment under 24-h circulation with EDTA-2Na/H2O and in the distal ATA segment under 24-h circulation with EDTA-3Na/H2O. The proximal ATA segment under 6-h circulation with EDTA-3Na/H2O showed no significant change in any parameters of calcium CONCLUSION: EDTA-3Na/H2O or EDTA-2Na/H2O with longer circulation times resulted in greater calcium reduction in atherosclerotic lesion. EDTA may have a potential therapeutic option for the treatment of atherosclerotic calcified lesions.
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Angioplastia de Balón , Ácido Edético , Estudios de Factibilidad , Calcificación Vascular , Animales , Ácido Edético/farmacología , Angioplastia de Balón/instrumentación , Porosidad , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/terapia , Cadáver , Arterias Tibiales/diagnóstico por imagen , Quelantes del Calcio/farmacología , Factores de Tiempo , Microtomografía por Rayos X , Humanos , Dispositivos de Acceso Vascular , Diseño de Equipo , Sus scrofa , Enfermedad Arterial Periférica/terapia , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/metabolismo , Placa Aterosclerótica , PorcinosRESUMEN
Importance Free tissue transfer for reconstruction of the head and neck requires complicated repair of complex anatomy. The posterior tibial flap is a free tissue flap that has viability and versatility to be used for complex reconstructions that is not offered by other free flaps. OBJECTIVE: The posterior tibial artery flap is a perforator flap which is found between the flexor digitorum longus and the soleus. It has been described as both a pedicled flap for lower extremity reconstruction as well as a free flap, including for head and neck reconstruction. Limited data exists on the subject in the English literature. The objective of this study is to present our experience with the flap in the head and neck. DESIGN: Retrospective review of cases from a single institution between October 2019 and May 2023. Primary indications included patients whose defects were felt to be larger than a conventional radial forearm free flap that were not well served by the anterolateral thigh flap, either because of body habitus or room for the associated muscle. SETTING: Tertiary academic hospital system performing free tissue transfer reconstruction of within the head and neck. RESULTS: Fifteen patients underwent posterior tibial artery free flap during the study period. Indications for flap reconstruction included oral cavity, tongue, oropharynx and skin of the scalp and forehead. Flap size ranged from 24cm2 to 143cm2. Only one flap failure was observed. Flap harvest time was universally under forty-six minutes, and as little as thirty-two. CONCLUSION: The posterior tibial artery flap is a useful option in head and neck reconstruction. It provides an intermediary in size and bulk between the radial forearm and the anterolateral thigh flap. Additionally, it provides a straightforward harvest with minimal donor site morbidity.
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Colgajos Tisulares Libres , Neoplasias de Cabeza y Cuello , Procedimientos de Cirugía Plástica , Arterias Tibiales , Humanos , Procedimientos de Cirugía Plástica/métodos , Masculino , Estudios Retrospectivos , Femenino , Persona de Mediana Edad , Arterias Tibiales/cirugía , Anciano , Neoplasias de Cabeza y Cuello/cirugía , Colgajos Tisulares Libres/irrigación sanguínea , Adulto , Colgajo Perforante/irrigación sanguíneaRESUMEN
OBJECTIVE: Patients with diabetes mellitus (DM) are at increased risk for peripheral artery disease (PAD) and its complications. Arterial calcification and non-compressibility may limit test interpretation in this population. Developing tools capable of identifying PAD and predicting major adverse cardiac event (MACE) and limb event (MALE) outcomes among patients with DM would be clinically useful. Deep neural network analysis of resting Doppler arterial waveforms was used to detect PAD among patients with DM and to identify those at greatest risk for major adverse outcome events. METHODS: Consecutive patients with DM undergoing lower limb arterial testing (April 1, 2015-December 30, 2020) were randomly allocated to training, validation, and testing subsets (60%, 20%, and 20%). Deep neural networks were trained on resting posterior tibial arterial Doppler waveforms to predict all-cause mortality, MACE, and MALE at 5 years using quartiles based on the distribution of the prediction score. RESULTS: Among 11,384 total patients, 4211 patients with DM met study criteria (mean age, 68.6 ± 11.9 years; 32.0% female). After allocating the training and validation subsets, the final test subset included 856 patients. During follow-up, there were 262 deaths, 319 MACE, and 99 MALE. Patients in the upper quartile of prediction based on deep neural network analysis of the posterior tibial artery waveform provided independent prediction of death (hazard ratio [HR], 3.58; 95% confidence interval [CI], 2.31-5.56), MACE (HR, 2.06; 95% CI, 1.49-2.91), and MALE (HR, 13.50; 95% CI, 5.83-31.27). CONCLUSIONS: An artificial intelligence enabled analysis of a resting Doppler arterial waveform permits identification of major adverse outcomes including all-cause mortality, MACE, and MALE among patients with DM.
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Enfermedad Arterial Periférica , Valor Predictivo de las Pruebas , Ultrasonografía Doppler , Humanos , Masculino , Femenino , Anciano , Enfermedad Arterial Periférica/fisiopatología , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/complicaciones , Medición de Riesgo , Persona de Mediana Edad , Factores de Riesgo , Aprendizaje Profundo , Reproducibilidad de los Resultados , Pronóstico , Anciano de 80 o más Años , Factores de Tiempo , Arterias Tibiales/diagnóstico por imagen , Arterias Tibiales/fisiopatología , Angiopatías Diabéticas/fisiopatología , Angiopatías Diabéticas/diagnóstico por imagen , Angiopatías Diabéticas/mortalidad , Angiopatías Diabéticas/diagnósticoRESUMEN
Two adult dogs were presented at 25 and 30 days following tibial external skeletal fixator placement (case 1) and tibial plateau leveling osteotomy (case 2), respectively. Clinical signs at presentation for each of them included acute onset lethargy, non-weight-bearing lameness, and hemorrhage at the surgical site with large hematoma formation. On admission, emergency whole blood transfusion was required in case 2 with a preoperative packed cell volume of 13%. Both dogs were diagnosed with pseudoaneurysm of the cranial tibial artery based on color Doppler ultrasonography. Additionally, computed tomography angiography was performed in one dog. Surgical treatment of the dogs included ligation of the cranial tibial artery supplying the pseudoaneurysm and curettage of hematoma. The surgery was completed without complications in case 1, but case 2 experienced inadvertent rupture of pseudoaneurysm with significant blood loss, which required another whole blood transfusion during the procedure. Both dogs had excellent functional recovery with no recurrence of clinical signs. We hypothesized that pseudoaneurysms were primarily caused by trauma secondary to placement of surgical implants or osteotomy. For orthopedic surgeons, it is important to recognize clinical signs of a potential tibial arterial pseudoaneurysm, as early surgical intervention may prevent loss of limb or life.
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Aneurisma Falso , Lesiones del Ligamento Cruzado Anterior , Enfermedades de los Perros , Perros , Animales , Ligamento Cruzado Anterior/cirugía , Lesiones del Ligamento Cruzado Anterior/cirugía , Lesiones del Ligamento Cruzado Anterior/veterinaria , Aneurisma Falso/complicaciones , Aneurisma Falso/cirugía , Aneurisma Falso/veterinaria , Arterias Tibiales , Enfermedades de los Perros/cirugía , Tibia/cirugía , Hemorragia/veterinaria , Hematoma/veterinaria , Rodilla de Cuadrúpedos/cirugíaRESUMEN
BACKGROUND: Selective operative management of injuries to the tibial arteries is controversial, with the necessity of revascularization in the face of multiple tibial arteries debated. Tibial artery injuries are frequently encountered in military trauma, but revascularization practices and outcomes are poorly defined. We aimed to investigate associations between the number of injured vessels and reconstruction and limb loss rates in military casualties with tibial arterial trauma. METHODS: A US military database of lower extremity vascular injuries from Iraq and Afghanistan (2004-2012) was queried for limbs sustaining at least 1 tibial artery injury. Injury, intervention characteristics, and limb outcomes were analyzed by the number of tibial arteries injured (1, T1; 2, T2; 3, T3). RESULTS: Two hundred twenty one limbs were included (194 T1, 22 T2, 5 T3). The proportions with concomitant venous, orthopedic, nerve, or proximal arterial injuries were similar between groups. Arterial reconstruction (versus ligation) was performed in 29% of T1, 63% of T2, and universally in T3 limbs (P < 0.001). Arterial reconstruction was via vein graft (versus localized repair) in 62% of T1, 54% of T2, and 80% of T3 (P = 0.59). T3 received greater blood transfusion volume (P = 0.02), and fasciotomy was used universally (versus 34% T1 and 14% T2, P = 0.05). Amputation rates were 23% for T1, 26% for T2, and 60% for T3 (P = 0.16), and amputation was not significantly predicted by arterial ligation in T1 (P = 0.08) or T2 (P = 0.34) limbs. Limb infection was more common in T3 (80%) than in T1 (25%) or T2 (32%, P = 0.02), but other limb complication rates were similar. CONCLUSIONS: In this series of military lower extremity injuries, an increasing number of tibial arteries injured was associated with the increasing use of arterial reconstruction. Limbs with all 3 tibial arteries injured had high rates of complex vascular reconstruction and eventual amputation. Limb loss was not predicted by arterial ligation in 1-vessel and 2-vessel injuries, suggesting that selective reconstruction in these cases is advisable.
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Traumatismos de la Pierna , Personal Militar , Lesiones del Sistema Vascular , Humanos , Arterias Tibiales/diagnóstico por imagen , Arterias Tibiales/cirugía , Arterias Tibiales/lesiones , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/cirugía , Lesiones del Sistema Vascular/complicaciones , Recuperación del Miembro , Factores de Riesgo , Resultado del Tratamiento , Traumatismos de la Pierna/cirugía , Estudios RetrospectivosRESUMEN
BACKGROUND: The free peroneal artery perforator (FPAP) flap is used for soft tissue defects after burns and trauma. However, the use of FPAP flaps to repair limb soft tissue defects for immediate reconstruction was rarely reported previously. Therefore, the purpose of this report is to evaluate free peroneal artery perforator flap to reconstruct traumatic limb soft tissue defects for immediate reconstruction. PATIENTS AND METHODS: A total of 25 cases of limb soft tissue defects undergoing immediate reconstruction of FPAP flap transfer were retrospectively evaluated from January 2019 to June 2019 in our institute. The locations of defects included the palm (10 cases), finger (5 cases), foot (7 cases), ankle (2 cases) and wrist (1 case). The sizes of defect varied from 3 × 2 cm to 15 × 7 cm (54.1 cm2 in average). Flaps were harvested based on the peroneal perforator vessels, initially marked using hand-held Doppler. RESULTS: Average size of harvested flap was 9.7 × 6.2 cm (ranging from 3.5 × 2 cm to 16 × 8 cm). All perforators were harvested from the peroneal artery and the arterial diameter ranged from 0.8 to 1.7 mm. The average pedicle length was 3.04 cm (range, 1.85-4.75 cm). Five vascular thrombosis were found including three cases of arterial thrombosis and two cases of venous thrombosis which were successfully salvaged by re-operation and vein graft. Satisfying functional outcome and acceptable appearance were achieved at 6 months or longer after surgery (range, 6-15 months, 12 months in average). All flaps survived at the end-point. CONCLUSIONS: The FPAP flap is a reliable and thin fasciocutaneous flap, which can be used for repairing limb soft tissue defects. The FPAP flap can be used for covering defects with various appearances, locations, and sizes.
Asunto(s)
Colgajo Perforante , Procedimientos de Cirugía Plástica , Traumatismos de los Tejidos Blandos , Trombosis , Humanos , Estudios Retrospectivos , Trasplante de Piel , Colgajo Perforante/irrigación sanguínea , Traumatismos de los Tejidos Blandos/cirugía , Arterias Tibiales/cirugía , Trombosis/cirugía , Resultado del TratamientoRESUMEN
OBJECTIVES: The objective of this study was to define the danger zone at which the anterior tibial artery (ATA) is at risk during anterolateral plating of the distal tibia using a novel 3D computed tomography angiography (CTA) modeling technique. METHODS: 116 patients (232 lower extremities) who underwent lower extremity CTAs between April 2020 and April 2022 were identified. Those with lower extremity trauma, evidence of a previously healed tibial fracture, or poor visualization of the ATA were excluded. The remaining 150 lower extremities (92 patients) were modeled with an anterolateral distal tibia plate using Sectra IDS7 software. The distance of the ATA from bony landmarks was measured perpendicular to the level at which the vessel intersected the plate. RESULTS: The ATA intersected the plate proximally at a mean distance of 10.5 cm (95% confidence intervals, 10.2-10.9) and at a mean distance of 4.6 cm (95% confidence intervals, 4.4-4.9) distally from the central tibial plafond. The ATA intersected with the plate as far distal as hole number 1 and as proximal as hole 14 of the plate. The greatest injury risk was associated with plate holes 3-8. In this region, the artery was at risk in 46-99 percent of specimens. CONCLUSIONS: The ATA is at risk when screws are placed percutaneously in an anterolateral distal tibia plate. The artery can be as close as 4.4 cm and as far as 10.9 cm proximal to the tibial plafond when crossing the plate, correlating to a risk of injury to the ATA at plate holes 1 through 14.
Asunto(s)
Tibia , Fracturas de la Tibia , Humanos , Tibia/diagnóstico por imagen , Tibia/cirugía , Tibia/irrigación sanguínea , Arterias Tibiales/diagnóstico por imagen , Arterias Tibiales/cirugía , Arterias Tibiales/lesiones , Fracturas de la Tibia/diagnóstico por imagen , Fracturas de la Tibia/cirugía , Fijación Interna de Fracturas/métodos , Tomografía Computarizada por Rayos X , Angiografía , Placas ÓseasAsunto(s)
Aneurisma Falso , Fístula Arteriovenosa , Arterias Tibiales , Humanos , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/etiología , Aneurisma Falso/cirugía , Aneurisma Falso/terapia , Fístula Arteriovenosa/diagnóstico por imagen , Fístula Arteriovenosa/etiología , Angiografía por Tomografía Computarizada , Embolización Terapéutica , Arterias Tibiales/diagnóstico por imagen , Arterias Tibiales/lesiones , Arterias Tibiales/cirugía , Resultado del Tratamiento , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/etiología , Lesiones del Sistema Vascular/cirugíaRESUMEN
BACKGROUND: Tibial artery calcification (TAC) is correlated with an increased risk of amputation and mortality in patients with chronic limb-threatening ischemia (CLTI). The association between calcification characteristics and adverse limb events of CLTI. However, it has not been assessed. This study aims to assess the relationship between the characteristics of TAC based on computed tomography angiography (CTA) scans and postoperative outcomes in patients with CLTI undergoing infrapopliteal endovascular therapy. METHODS: This was a retrospective study of patients who underwent infrapopliteal endovascular revascularization for CLTI and had a preoperative CTA scan. Based on CTA, TAC was divided into the following categories: annularity, thickness, continuity and severity. Cox regression models using generalized estimating equations were performed to assess the relationship between calcification characteristics and postoperative outcomes. The outcomes evaluated were the occurrence of all cause mortality (ACM) and unplanned amputation. RESULTS: Among the 148 patients undergoing endovascular, there were 50 (33.8%) patients died and 26 (17.6%) patients underwent unplanned amputation. Annular calcification was more common in the ACM group than in the non-ACM group. No significant differences were found between the two groups with regard to the probability of calcification in the thickness and the continuity (P>0.05). Patients in the unplanned amputation group had significantly annular, thin and continuity calcifications (P<0.05) than those in the non-unplanned amputation group. The presence of annular calcification was an independent predictor of ACM (hazard ratio (HR), 3.186; 95% confidence interval (CI), 1.781-5.702; P<0.001) and unplanned amputation (HR, 3.739; 95% CI, 1.707-8.191; P<0.05). CONCLUSIONS: Among patients with CLTI, the occurrence of annular calcification in the tibial artery are related to a greater chance of ACM and unplanned amputation in the postoperative period. The circumferential degree of TAC of the operated limb can be considered as a marker of clinical prognosis in this group of patients.
Asunto(s)
Procedimientos Endovasculares , Enfermedad Arterial Periférica , Humanos , Isquemia Crónica que Amenaza las Extremidades , Arterias Tibiales/diagnóstico por imagen , Arterias Tibiales/cirugía , Procedimientos Endovasculares/métodos , Factores de Riesgo , Estudios Retrospectivos , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/cirugía , Resultado del Tratamiento , Isquemia/diagnóstico por imagen , Isquemia/cirugía , Recuperación del Miembro/efectos adversos , Recuperación del Miembro/métodos , Enfermedad CrónicaRESUMEN
Objective: To investigate the architecture of the cutaneous branch-chained blood vessels in the medial lower leg and provide the anatomical basis for design and clinical application of the cutaneous branch-chained flap from this region. Methods: The experimental research method was used. From March to May 2023, the anatomical study was conducted on the 5 voluntarily donated fresh adult (aged 50 to 70 years, all male) cadaveric specimens from Hangzhou Normal University School of Basic Medical Sciences. The fine anatomy under microscope was performed on each lower leg specimens of 5 corpses (1 lower leg specimen was conducted with digital radiography (DR) scan before fine anatomy), to observe, measure, and record the course of posterior tibial artery, quantity of perforator, the distance between the perforating point of each perforator and the medial condyle of tibia, the external diameter of posterior tibial artery perforator, the length of perforator pedicle, the horizontal distance between the posterior tibial artery perforator and the saphenous nerve, and the course of each perforator within superficial fascia after crossing the deep fascia and the distribution of the cutaneous branch-chains. The DR scan under the perfusion of barium sulfate was conducted in one lower leg specimen to observe the distribution of cutaneous branch-chained vascular network (hereinafter referred to as vascular chain) between perforators. Transparent skin specimen was made from one leg specimen after anatomy to observe the distribution of perforators and vascular chains between perforators. Results: In 5 lower leg specimens, the upper part of posterior tibial artery was located deep in soleus muscle, and the lower part was located between the medial edge of gastrocnemius muscle and flexor digitorum longus muscle. A total of 28 posterior tibial artery perforators were identified, with an average of 5.6 branches in each lower leg. The distance between the perforating point of perforator and the medial condyle of tibia ranged from 6.5 to 36.0 cm, mainly distributed at 22.0 (15.1, 28.1) cm from the medial condyle of tibia, in zones 3 to 6. The external diameters of perforators of posterior tibial arteries were 0.7-1.1 mm. The length of perforator pedicle was 1.0-4.5 cm, and the horizontal distance between the posterior tibial artery perforator and the saphenous nerve was 0.5-3.0 cm. The fine anatomy under microscope showed that the posterior tibial artery perforators had long upward and downward branches after crossing the deep fascia, and the ascending branches and descending branches were anastomosed longitudinally to form the nutrient cutaneous branch-chain in the medial lower leg. DR scan and transparent skin specimen both showed that longitudinal vascular chain was formed between the posterior tibial artery perforators, the transparent skin specimen also showed that longitudinal blood vessel chains included the direct connecting vessels in the adipose layer and the indirect connecting vessels in the subdermal layer. Conclusions: The cutaneous branch-chained vessels in the medial lower leg are constructed by posterior tibial artery perforators, direct connecting vessels, indirect connecting vessels, and traffic branches. The cutaneous branch-chained flap is reliable in terms of vascular anatomy, and can carry the saphenous nerve for partial restoration of its sensation, thus it is an ideal flap.
Asunto(s)
Pierna , Colgajo Perforante , Adulto , Humanos , Masculino , Pierna/irrigación sanguínea , Pierna/cirugía , Extremidad Inferior , Colgajos Quirúrgicos/irrigación sanguínea , Arterias Tibiales/anatomía & histología , Arterias Tibiales/cirugía , Tibia , Colgajo Perforante/irrigación sanguíneaRESUMEN
Below-the-knee (BTK) pseudoaneurysms that occur after endovascular therapy (EVT) and result in delayed rupture have rarely been reported. In this report, we present a rare case of an 86-year-old man with chronic limb-threatening ischemia who developed delayed rupture of an idiopathic pseudoaneurysm of the peroneal artery (PA) following EVT. The PA chronic total occlusion (CTO) was successfully crossed using a guidewire via an antegrade approach, however, subintimal crossing was confirmed by intravascular ultrasound. Balloon angioplasty was then performed using an appropriately sized balloon, resulting in successful recanalization of the PA CTO with minor dissection and no complications. Postoperatively, the patient's condition was stable until he suddenly complained of right calf pain 10 days after EVT. Computed tomography revealed a rupture of the PA pseudoaneurysm. Urgent angiography revealed two pseudoaneurysms, one saccular and the other spindle-shaped. The ruptured saccular aneurysm was successfully excluded through coil embolization and stent graft placement. To the best of our knowledge, this is the first reported case of delayed rupture of a BTK pseudoaneurysm following EVT. Balloon angioplasty in the subintimal space can lead to the formation of a pseudoaneurysm and its delayed rupture.
Asunto(s)
Aneurisma Falso , Masculino , Humanos , Anciano de 80 o más Años , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/etiología , Aneurisma Falso/cirugía , Isquemia Crónica que Amenaza las Extremidades , Resultado del Tratamiento , Pierna/irrigación sanguínea , Arterias TibialesRESUMEN
CASE: A 46-year-old man with vascular Ehlers-Danlos syndrome (EDS) had an open ankle fracture with a 10 × 5-cm skin defect on the medial side of the ankle. The patient underwent open reduction and internal fixation, as well as coverage of the skin defect with a posterior tibial artery perforator flap, which led to successful outcomes. CONCLUSION: We present the successful implementation of a posterior tibial artery perforator flap for the reconstruction of skin defects in a patient with vascular EDS. Despite the fragility of soft tissues, favorable surgical outcomes were observed.