Fibular free flap with proximal perforator skin paddle due to aberrant anatomy - a case report

BACKGROUND

The fibular free flap is considered one of the most valuable options for mandible reconstruction. A perforator flap has gained widespread acceptance in oral and maxillofacial reconstruction. Typically, the fibula flap is obtained primarily with the distal perforator due to its reliable blood supply, with less attention given to the proximal perforators during the harvesting process. Normally, the distal perforator of the fibula exhibits stability and shows limited anatomical variations. However, there have been reported cases in which the distal perforator is absent. At times, these vascular abnormalities remain undetectable through Doppler examination or preoperative angiography evaluation. Therefore, this case details the experience of encountering the rare event of vascular abnormality in oral cancer surgery.

CASE PRESENTATION

This article reports the case of a patient who presented with a congenital absence of the distal perforator in the peroneal artery, attributed to a vascular abnormality. Additionally, we provide a review of the concept of utilizing the proximal perforator as an alternative approach in the flap harvesting process.

CONCLUSIONS

While the distal perforator of the peroneal artery is typically utilized for fibula free flap procedures, surgeons must remain cognizant of the potential for its absence due to aberrant anatomy. Recognizing an alternative approach in such cases can be pivotal for precise surgical planning and favorable outcomes in oral and maxillofacial reconstruction.

Diode laser photocoagulation of intraoral (and perioral) venous malformations: Cases series

Vascular anomalies are subdivided into vascular tumors (hemangiomas) and vascular malformations. They are frequently located in the head, neck, and oral cavity. They are common complaints reported in patients seeking treatment for aesthetic or functional issues. However, recent advances in the diagnosis and management of these lesions are improving treatment strategies. This review provides both basic and up-to-date knowledge on the most common vascular anomalies encountered by practitioners. Due to the wide variability of treatment options which often generates debate, this paper work aims to provide a comprehensive approach of these lesions based upon current concepts and practical clinical experience. Our article is about 4 patients who had consulted for one or several purplish, elevated, well limited and soft lesion. These lesions was not painful, but worrying for patients. Therapies for VAs continue to generate a dilemma for oral surgeons. Several treatment options were reported, including conventional surgery with or without adjunctive preoperative embolization, and drug therapies, such corticosteroids, intralesional injection of corticosteroids and intralesional injections of sclerosing agents. All of these therapeutic approaches carry a high risk of severe side effects such as scars, pain, and bleeding [7]. Nowadays, advances in the use of lasers have allowed doctors an effective treatment with minimal side effects [9]. All our cases described in this article were done by Pr Haitami, using the 980 nm Diode laser, and a complete healing was observed in about 8 months at the most. The laser is therefore a great help in the management of this type of lesion.

Prevalence of Vertebral artery anomaly in upper cervical and its surgical implications: a systematic review

BACKGROUND

The presence vertebral artery (VA) abnormalities in the upper cervical may be a potential cause of catastrophic complication in the posterior approach of the upper cervical spine surgery. The aim of this study was to demonstrate the real incidence of the V3 segment anomaly in patients who need upper cervical surgery, and tried to find out the risk factors of V3 segment anomaly to evaluate the necessary of computed tomographic angiography (CTA) for upper cervical surgery.

METHOD

This systematic review was conducted following the preferred reporting items for systematic reviews and meta-Analyses (PRISMA). Retrospective studies and reports of case series involving human subjects with data on anomalies of vertebral artery in upper cervical spine were included. Data on the prevalence of persistent first intersegmental artery (PIA), fenestration of the VA (FA), posterior inferior cerebellar artery (PICA) were extracted.

RESULTS

A total of 16 articles involving 5927 subjects met the inclusion criteria. The total incidence of V3 segment anomaly in the patients with bony abnormalities was 25.9% (74/286): PIA was 17.5%, FA was 6.6% and PICA was 1.8%. The total incidence of V3 segment anomaly in the patients without bony abnormalities was 2.7% (152/5671): PIA was 1.76%, FA was 0.4% and PICA was 0.5%. The total incidence of V3 segment anomaly in Asian population without bony abnormalities was 5.8%, while in European and American population was 0.8 and 0.6%, respectively.

CONCLUSION

Patients with bone abnormalities are high risk factor for VA abnormalities, CTA is of paramount importance to evaluate the variant VA anatomy. However, regarding to the low incidence of V3 variation in normal population, we do not recommend preoperative CT angiography as mandatory part of preoperative.

Surgical treatment of esophageal cancer with anomaly of the aortic arch and its branches

BACKGROUND

Anomalies of the aortic arch and its branches rarely develop. The surgery for esophageal cancer may be challenging with the presence of these anomalies. This study is aimed to analyze the influence of these variations during the esophagectomy.

METHODS

A total of 21 patients with aortic arch and brachiocephalic vessel variations were retrospectively identified from 2013 to 2019. Anomalies were distributed: 15 patients with left-sided aortic arch combined with aberrant right subclavian artery (LAA + ARSA), 2 right-sided aortic arch with mirror-image arch branches (RAA + MIAB), and 4 right-sided aortic arch combined with aberrant left subclavian artery (RAA + ALSA). Perioperative characteristics and long-term survival were analyzed.

RESULTS

Tumors were mostly located in the upper and middle thorax (42.9% and 47.6%, respectively). Of the 15 patients with LAA + ARSA, 13 underwent McKeown esophagectomy and 2 via transhiatal approach. Left thoracotomy was performed on all 6 patients with RAA. The R0 resection rate was 90.5% (19/21). Recurrent laryngeal nerve (RLN) injury occurred in 2 patients. Two patients died within 30 days postoperatively. Lymph node yield was 23.6 ± 1.2, with a metastasis rate of 38.1% (8/21). The median follow-up time was 18 months. Recurrence occurred in 6 patients (11-35 months) and 4 patients died after recurrence with a median time to death of 21 months (8-47 months).

CONCLUSION

For resectable esophageal cancer combined with aortic arch and its branches anomalies, satisfactory surgical results can be obtained under careful preoperative evaluation and reasonable surgical approach selection.

Anomalous origin of the middle colic artery from the ileocecal artery affecting laparoscopic ascending colon cancer resection

The anomalies of the middle colic artery have rarely been reported and reviewed in literature. However, in case such anomalies are observed in clinical practice, surgery must still be performed safely. This report presents the case of a 78-years-old female who underwent ileocecal resection and hepatectomy due to ascending colon cancer with liver metastasis. Preoperative abdominal contrast-enhanced computed tomography showed an anomaly of the middle colic artery. Since such anomaly is extremely rare, preoperative evaluation of vascular structure is important for safely performing the surgery.

Supraclavicular nerve entrapment by the external jugular vein: An unreported finding

OBJECTIVE

We aim to describe the supraclavicular nerve's vascular entrapment by the external jugular vein as an unreported anatomical finding.

CASE DESCRIPTION

In a routine cadaveric dissection, the superficial emergence of the first division of the left supraclavicular nerve emerged along a duct formed through the external jugular vein. No other vascular or neural anatomical abnormalities were found in the surrounding structures.

CONCLUSION

This unreported vascular entrapment of the supraclavicular nerve by the external jugular may harbour clinical implications for surgical and endovascular procedures on the external jugular vein and in refractory thoracic and scapular waist pain.

Aneurysms in primary antiphospholipid syndrome: a case-based review

To perform a review on patients with primary antiphospholipid syndrome (APS) who developed an aneurysm. A review of articles published in PubMed/MEDLINE, LILACS, and SciELO dating from 1966 to October 2020 was conducted using the following search words: "Antiphospholipid syndrome" and "aneurysm." No language limitation was applied. This review includes 10 articles on APS patients and aneurysms entailing 14, including our additional case. Age varied from 20 to 76 years old, and female sex was predominant and presented in 54%. The arterial vessels compromised were aorta (n = 6), coronary (n = 2), hepatic (n = 2), renal (n = 2), middle cerebral artery (n = 2), and then splenic, superior mesenteric, pancreatic, retinal, jejunal, carotid, and pulmonary. Frequencies of antiphospholipid antibodies were described as follows: lupus anticoagulant (n = 6), anti-beta2-glycoprotein I (n = 4), IgG and IgM anticardiolipin (n = 3), IgG anticardiolipin (n = 3), and antiphosphatidylserine (n = 2). The presence of APS manifestations was distributed as deep venous thrombosis (n = 4), recurrent abortions (n = 4), pulmonary embolism (n = 3), stroke, or transitory ischemic accident (n = 3), and then limb ischemia and thrombocytopenia. The therapies used in these patients were warfarin, antiplatelet agent, vascular surgery, heparin, hydroxychloroquine, coil embolism, and intravenous immunoglobulin. Regarding outcomes, 5 patients were alive, and 3 were dead. This article reviewed all published cases on APS and aneurysm and showed that women who presented with abortions and deep venous thromboses with a lupus anticoagulant are those patients more commonly affected by aneurysms in APS.

Pathological angiogenesis and inflammation in tissues

The role of angiogenesis in the growth of organs and tumors is widely recognized. Vascular-organ interaction is a key mechanism and a concept that enables an understanding of all biological phenomena and normal physiology that is essential for human survival under pathological conditions. Recently, vascular endothelial cells have been classified as a type of innate immune cells that are dependent on the pathological situations. Moreover, inflammatory cytokines and signaling regulators activated upon exposure to infection or various stresses play crucial roles in the pathological function of parenchymal cells, peripheral immune cells, stromal cells, and cancer cells in tissues. Therefore, vascular-organ interactions as a vascular microenvironment or tissue microenvironment under physiological and pathological conditions are gaining popularity as an interesting research topic. Here, we review vascular contribution as a major factor in microenvironment homeostasis in the pathogenesis of normal as well as cancerous tissues. Furthermore, we suggest that the normalization strategy of pathological angiogenesis could be a promising therapeutic target for various diseases, including cancer.

Anomalous retinal artery associated with branch retinal artery occlusion and neovascular glaucoma: A case report

BACKGROUND

Congenital anomalous retinal artery is rare and does not typically affect visual acuity. However, an abnormal artery that passes through and supplies blood to the macular area complicated with branch retinal artery occlusion may negatively impact visual acuity. This study reports an unusual case of anomalous retinal artery combined with retinal artery occlusion.

CASE SUMMARY

A 52-year-old male presented with severely reduced vision in the right eye. The fundus examination revealed an anomalous artery, extending from the superior temporal arcade and crossing the macula into the inferior temporal quadrant. The anomalous artery was partially occluded, with a narrowed lumen. A cherry-red spot was observed with whitening of the macular area, suggesting macular edema. Fundus fluorescein angiography revealed disc leakage and a delayed filling time. Optical coherence tomography revealed increased thickness of the neuroretina and underlying layers. The patient was treated with vessel dilation, hyperbaric oxygen, ocular massage, and thrombolytics. Visual acuity of the right eye subsequently improved to 20/200 from hand motion at 4 cm. This improvement in visual acuity persisted when the patient was examined at the 1-mo follow-up visit. The patient was subsequently followed via telephone interview. The information provided via interview indicated that visual acuity in the affected eye was stable up to 6 years from the time of the initial presentation. However, after 3 additional years, the patient was diagnosed with neovascular glaucoma in the right eye, which was subsequently enucleated.

CONCLUSION

Although congenital retinal vascular anomaly, including anomalous retinal artery, rarely affects vision, when complicated with branch retinal artery occlusion, the abnormal artery that supplies the macula may severely reduce visual acuity.

A boy with Alagille syndrome coexisting with mid-aortic syndrome and renovascular hypertension

Background

Alagille syndrome (ALGS) is characterized by cholestasis due to paucity of intrahepatic bile ducts, cardiac anomalies, ophthalmologic abnormalities, skeletal abnormalities, and characteristic facies. Mid-aortic syndrome (MAS) is a rare entity characterized by segmental narrowing of the proximal abdominal aorta and ostial stenosis of its major branches. We report a case of ALGS with MAS involving severe renal artery stenosis (RAS).

Case

A four-year-old Japanese boy was referred to our hospital because of cholestatic liver dysfunction. He was diagnosed with ALGS due to having all five characteristic hallmarks. He had high blood pressure (152/84 mmHg) at his first visit. 3D-CT angiography showed coarctation of the abdominal aortic trunk, severe ostial stenosis of the celiac artery, superior mesenteric artery, and bilateral RAs. He was diagnosed with MAS, and treated with metoprolol, cilnidipine, and aspirin.

Discussions

While vascular abnormalities are reported to occur in 9% of ALGS patients, MAS with ALGS was only reported in 11 patients between 1951 and 2011. In Japan, there were no reports of ALGS coexisting with MAS with the exception of one case with RAS. In addition to the vessels of the heart, it is important to examine patients with ALGS for abnormalities of other vessels.<Learning objective: Mid-aortic syndrome (MAS) is a rare entity characterized by segmental narrowing of the proximal abdominal aorta and ostial stenosis of its major branches. While MAS is a very rare complication in case of Alagille syndrome (ALGS), it results in significant morbidity and mortality. Thus, surveillance for vascular abnormalities not only in the heart but also other vessels is important in ALGS.>.

Sex-Specific Differences in Clinical Characteristics and Outcomes Among Patients with Vascular Abnormality-Related Intracerebral Hemorrhage

BACKGROUND

Results are conflicting as to whether sex has an impact on the outcome of intracerebral hemorrhage (ICH), especially when etiologies differ. In this study, we investigated whether sex differences exist in patients with vascular abnormality-related ICH.

METHODS

Patients (age ≥18 years) diagnosed with ICH within 7 days of symptom onset were admitted consecutively between January 2012 and February 2014 from 50 hospitals across mainland China. Vascular abnormality related to ICH included aneurysm, arteriovenous malformation, moyamoya disease, and cavernous malformation. The outcomes were death and death/disability at 3 months. Disability was defined as modified Rankin Scale score >2. Multivariable logistic regression was used to estimate the association between sex and outcome.

RESULTS

Women accounted for 41.9% (170) of the 406 patients, and they tended to be older than the men (women: 43.5 ± 19.3 years; men: 40.0 ± 17.7 years; P = 0.056). The proportions of ICH-related vascular abnormalities were as follows: aneurysm, 32% (130/406); arteriovenous malformation, 50.3% (204/406); moyamoya disease, 11.3% (46/406); and cavernous malformation, 6.4% (26/406). After we adjusted for age, National Institute of Health Stroke Scale, Glasgow Coma Scale score, location of hemorrhage, and surgery, female sex remained an independent predictor of death/disability at 3 months (odd ratio 2.49, 95% confidence interval 1.31-4.75), but not for death alone (odd ratio 1.45, 95% confidence interval 0.58-3.61).

CONCLUSIONS

In our study, female sex was an independent risk factor for poor outcomes in patients with vascular abnormality-related ICH. The factors contributing to this sex difference should be investigated in the future.

Case report

Tonsillectomy and adenoidectomy are the most common surgical procedures in pediatric otolaryngology. The incidence of primary hemorrhage after tonsillectomy in children ranges from 0.38 to 6%. The prevalence of secondary bleeding occurs in 0.5%-9.3% cases [1]. Authors present a case of an 11-year-old girl who experienced 6 delayed, massive post-tonsillectomy bleedings as a result of presence of vascular malformation and the activation of collateral circulation as a result of the left ECA ligature.