Epithelioid Hemangioma of the Popliteal Artery: A Case Report

An epithelioid hemangioma (EH) is a rare benign vascular lesion that is usually seen in superficial small vessels within the dermis and subcutaneous tissue. Intravascular epithelioid hemangiomas of large and medium-sized vessels are rare, and only a handful of cases have been reported in the literature. Intravascular epithelioid hemangiomas are biologically benign and best treated by complete surgical excision. On occasion, lesions have been associated with aneurysmal changes in the affected vessel. Local recurrence may occur, and close clinical follow-up is advised. Herein, we report the second case in the literature of an EH originating from the popliteal artery. A 57-year-old male patient presented with a one-month history of knee pain without claudication. Imaging highlighted a right popliteal aneurysm, 5x5 cm, with partial distal thrombosis and inadequate outflow. The patient subsequently underwent popliteal artery ligation above and below the aneurysm, reconstructed with a superficial femoral artery (SFA) to distal anterior tibial artery (ATA) reverse saphenous vein bypass graft. Patient recovery was complicated by the development of a 5x5 cm right-sided mid-thigh hematoma, requiring evacuation under anesthesia. A post-one-year arterial duplex of the affected limb demonstrated a recurrent enlarging popliteal aneurysm measuring 5.7x4.8x9.1 cm. The aneurysm was reported to be mostly thrombosed with noted vascularity, but patency of the original bypass was noted. The patient underwent excision of the recurrent aneurysm with subsequent ligation of the feeding arteries. Pathology and histology confirmed the final diagnosis of EH of the popliteal artery. An 18-month follow-up after the excision procedure demonstrated no recurrence of vascular lesion and patency of the original bypass graft.

Extracranial/Intracranial Vascular Bypass in the Treatment of Head and Neck Cancer - Related Carotid Blowout Syndrome

OBJECTIVE/HYPOTHESIS

To investigate the endovascular intervention or extracranial/intracranial (EC/IC) vascular bypass in the management of patients with head and neck cancer-related carotid blowout syndrome (CBS).

STUDY DESIGN

Retrospective case series.

METHODS

Retrospective analysis of clinical data of patients with head and neck cancer-related CBS treated by endovascular intervention and/or EC/IC vascular bypass, analysis of its bleeding control, neurological complications, and survival results.

RESULTS

Thrity-seven patients were included. Twenty-five were associated with external carotid artery (ECA); twelve were associated with internal or common carotid artery (ICA/CCA). All patients with ECA hemorrhage were treated with endovascular embolization. Of the 12 patients with ICA/CCA hemorrhage, 9 underwent EC/IC bypass, 1 underwent endovascular embolization, and 3 underwent endovascular stenting. For patients with ECA-related CBS, the median survival was 6 months, and the 90-day, 1-year, and 2-year survival rates were 67.1%, 44.7%, and 33.6%, respectively; the estimated rebleeding risk at 1-month, 6-month, and 2-year was 7.1%, 20.0%, and 31.6%, respectively. For patients with ICA/CCA-related CBS, the median survival was 22.5 months, and the 90-day, 1-year, and 2-year survival rates were 92.3%, 71.8%, and 41.0%, respectively; the estimated rebleeding risk at 1 month, 6 months, and 2 years is 7.7%,15.4%, and 15.4%, respectively. ICA/CCA-related CBS patients have significantly longer survival time and lower risk of rebleeding, which may be related to the more use of EC/IC vascular bypass as a definite treatment.

CONCLUSIONS

For patients with ICA/CCA-related CBS, if there is more stable hemodynamics, longer expected survival, EC/IC vascular bypass is preferred.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1548-1556, 2021.

The Orthopedic-Vascular Multidisciplinary Approach Improves Patient Safety in Surgery for Musculoskeletal Tumors: A Large-Volume Center Experience

Objective: Wide-margin resection is mandatory for malignant bone and soft tissue tumors. However, this increases the complexity of resections, especially when vessels are involved. Patients in this high-risk clinical setting could be surgically treated using the multidisciplinary orthopedic-vascular approach. This study was carried out in this healthcare organization to evaluate patient safety in term of oncologic outcomes and reduction of the complication rate. Materials and Methods: We retrospectively reviewed 74 patients (37 males, 37 females; mean age 46 years, range 9–88) who underwent surgical excision for bone/soft tissue malignant tumors closely attached to vascular structures from October 2015 to February 2019. Vascular surgery consisted of isolation of at least one vessel (64 patients), bypass reconstruction (9 patients), and end-to-end anastomosis (1 patient). Mean follow-up was 27 months. Patients’ demographics, tumor characteristics, adjuvant treatments, type of orthopedic and vascular procedures, and oncologic and functional outcomes and complications were recorded. Results: Overall survival was 85% at 3 years follow-up. In total, 22 patients experienced at least one major complication requiring further surgery and 13 patients experienced at least one minor complication, whereas 17 reported deviations from the normal postoperative course without the need for pharmacological or interventional treatment. Major complications were higher in pelvic resections compared to limb-salvage procedures (p = 0.0564) and when surgical time was more than 4 h (p = 0.0364) at univariate analysis, whereas the most important multivariate independent predictors for major complications were pelvic resection (p = 0.0196) and preoperative radiotherapy (p = 0.0426). Conclusions: A multidisciplinary ortho-vascular approach for resection of malignant bone and soft tissue tumors tightly attached to important vascular structures should be considered a good clinical practice for patient safety.

Surgical wound dehiscence complicated by methicillin-resistant Staphylococcus aureus infection in a diabetic patient with femorotibial vascular bypass occlusion

Diabetic patients with critical limb ischaemia may be affected by severe wound and skin ulcer infections. We report a case of a patient with bilateral femorotibial occlusion and methicillin-resistant Staphylococcus aureus infection. The patient was treated with femoroperoneal vascular bypass, debridement of wound dehiscence and targeted antimicrobial therapy for symptom resolution and healing of the wound.

Major Histocompatibility Complex-Matched Arteries Have Similar Patency to Autologous Arteries in a Mauritian Cynomolgus Macaque Major Histocompatibility Complex-Defined Transplant Model

Background

Arterial bypass and interposition grafts are used routinely across multiple surgical subspecialties. Current options include both autologous and synthetic materials; however, each graft presents specific limitations. Engineering artificial small‐diameter arteries with vascular cells derived from induced pluripotent stem cells could provide a useful therapeutic solution. Banking induced pluripotent stem cells from rare individuals who are homozygous for human leukocyte antigen alleles has been proposed as a strategy to facilitate economy of scale while reducing the potential for rejection of induced pluripotent stem cell–derived transplanted tissues. Currently, there is no standardized model to study transplantation of small‐diameter arteries in major histocompatibility complex–defined backgrounds.

Methods and Results

In this study, we developed a limb‐sparing nonhuman primate model to study arterial allotransplantation in the absence of immunosuppression. Our model was used to compare degrees of major histocompatibility complex matching between arterial grafts and recipient animals with long‐term maintenance of patency and function. Unexpectedly, we (1) found that major histocompatibility complex partial haplomatched allografts perform as well as autologous control grafts; (2) detected little long‐term immune response in even completely major histocompatibility complex mismatched allografts; and (3) observed that arterial grafts become almost completely replaced over time with recipient cells.

Conclusions

Given these findings, induced pluripotent stem cell–derived tissue‐engineered blood vessels may prove to be promising and customizable grafts for future use by cardiac, vascular, and plastic surgeons.

Open repair of intraoperative popliteal artery injury during total knee arthroplasty in a patient with severe hemophilia A: A case report and literature review

RATIONALE

Arterial injuries during total knee arthroplasty (TKA) though rare may occur. Hemophilia may further challenge the management of such injury.

PATIENT CONCERNS

A 48-year-old male patient with severe hemophilia type A and stiff knee arthropathy underwent bilateral TKAs. Left popliteal artery injury was detected at the end of the left TKA.

DIAGNOSES

Urgent angiography confirmed the diagnosis of the left popliteal artery transection.

INTERVENTIONS

With clotting factor VIII replacement treatment, open repair was performed by end-to-end vascular bypass with the autograft of the large saphenous vein. No anticoagulant and antiplatelet treatment was administered postoperatively. Doses of the factor VIII were decreased step by step postoperatively.

OUTCOMES

Left lower limb was reperfused 4 hours after the onset of the ischemia. The patient recovered uneventfully. Postoperative Doppler examination showed the left popliteal artery remained patent.

LESSONS

The hemophilia may endanger the patients to higher risk of arterial injury during TKA because of the severe deformity and fibrosis around knee joint. For the hemophilia patients, with rational coagulation factor replacement therapy, open repair with autograft was an effective revascularization procedure for artery injury.

Impact of post-hospital cardiac rehabilitation on the quality of life of patients after surgical treatment for coronary artery disease

INTRODUCTION

The quality of life of cardiovascular patients is worse than that of healthy individuals. Pain, dyspnea, and fatigue impair daily activities, which in turn leads to decreased life satisfaction and emotional deterioration. The objective of comprehensive treatment, including early rehabilitation, is to reduce the risk of complications, progression, and recurrence of the disease, as well as to restore, maintain, or improve all aspects of the patient's quality of life to the greatest extent possible.

AIM

To assess the quality of life of patients who underwent surgical treatment for coronary artery disease and completed the second phase of cardiac rehabilitation.

MATERIAL AND METHODS

The study enrolled 100 patients undergoing early cardiac rehabilitation in stationary conditions after coronary artery bypass grafting. The group included 21 women and 79 men; their age ranged from 40 to 75 years. The study employed a questionnaire of our own design.

RESULTS

Post-hospital cardiac rehabilitation resulted in quality of life improvements, especially with regard to psychological aspects, reducing the occurrence of anxiety from 44% to 21%. In addition, the rehabilitation program reduced the occurrence of subjective ailments such as chest pain (from 68% to 10%), fatigue (from 40% to 33%), and dyspnea (from 50% to 12%).

CONCLUSIONS

Despite the achievement of quality of life improvements among patients after surgery coronary artery by-pass grafting and early cardiac rehabilitation, the result is not fully satisfactory. Systematic treatment and education should be continued to further improve the health of patients.

Omentum Free Flap Anastomosed to Arterial Bypass in Open Knee Dislocation: Case Report and Discussion

OBJECTIVE

To report on the original surgical management of a patient with severe trauma of both legs involving anastomosis of an omentum free flap with an emergency vascular bypass.

METHODS

After stabilization of the knee with an external fixator, a femoral-tibial bypass graft was performed to revascularize the leg with the contralateral great saphenous vein. Ten days later, an omentum free flap was used with an end-to-side arterial anastomosis between the right gastroepiploic artery and bypass graft to cover the loss of leg substance.

DISCUSSION

Anastomosis of a free flap with a single axis exposes the patient to risks of thrombosis and amputation. Lengthening of the arterial pedicle of the flap by venous graft or vascular loop might have allowed for avoidance of connection to the bypass. Nevertheless, the saphenous vein, generally used in these indications, was already harvested. The transitional anastomosis of the flap to the contralateral leg could not be considered because of the leg amputation. End-to-side anastomosis to the bypass presents many advantages: anastomosis with a healthy vessel without posttraumatic vascular disease, the superficial characteristics of the bypass, and lower incongruence of the thickness between the vessels compared with an anastomosis performed directly on the superficial femoral artery.

CONCLUSION

A free flap anastomosed to an emergency arterial bypass is a rare situation, which is not without risk, but it is an option that is justified by its technical simplicity. However, it should only be considered in exceptional circumstances.

Hypothyroidism and the risk of lower extremity arterial disease

BACKGROUND

Although an independent association between hypothyroidism and coronary artery disease has been demonstrated, few studies have examined the association between hypothyroidism and peripheral arterial disease. In the current study, we test the hypothesis that there is an independent association between hypothyroidism and lower extremity arterial disease.

METHODS

We retrospectively compared the prevalence of hypothyroidism in patients who had infra-inguinal arterial bypass surgery over a 6-year period with that of a control group of surgical patients who had pure cardiac valve surgery during the same time period. Both unadjusted and adjusted odds ratios were calculated to estimate the association between hypothyroidism and lower extremity arterial disease.

RESULTS

A total of 614 cases and 529 control subjects had surgery during the study period. When comparing all subjects, there was no association between hypothyroidism and lower extremity arterial disease (unadjusted odds ratio 0.88; 95% confidence intervals [CI]: 0.61-1.28). However, gender was found to be a significant effect modifier (P < 0.001), and gender-stratified analyses were subsequently performed. In men, there was a positive independent association between hypothyroidism and lower extremity arterial disease (adjusted odds ratio 2.65; 95% CI: 1.19-5.89), whereas in women there was a negative independent association (adjusted odds ratio 0.22; 95% CI: 0.11-0.46).

CONCLUSIONS

Gender is a significant effect modifier for the association between hypothyroidism and lower extremity arterial disease. The association is positive in men and negative in women. Future prospective studies that evaluate hypothyroidism as a risk factor for peripheral arterial disease should consider gender stratification in order to corroborate this finding.