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JACC. Cardiovascular Interventions Oct 2019This study sought to describe the angiographic characteristics, strategy associated with perforation, and the management of perforation during chronic total occlusion... (Comparative Study)
Comparative Study
OBJECTIVES
This study sought to describe the angiographic characteristics, strategy associated with perforation, and the management of perforation during chronic total occlusion percutaneous coronary intervention (CTO PCI).
BACKGROUND
The incidence of perforation is higher during CTO PCI compared with non-CTO PCI and is reportedly highest among retrograde procedures.
METHODS
Among 1,000 consecutive patients who underwent CTO PCI in a 12-center registry, 89 (8.9%) had core lab-adjudicated angiographic perforations. Clinical perforation was defined as any perforation requiring treatment. Major adverse cardiac events (MAEs) were defined as in-hospital death, cardiac tamponade, and pericardial effusion.
RESULTS
Among the 89 perforations, 43 (48.3%) were clinically significant, and 46 (51.7%) were simply observed. MAE occurred in 25 (28.0%), and in-hospital death occurred in 9 (10.1%). Compared with nonclinical perforations, clinical perforations were larger in size, more often at a collateral location, had a high-risk shape, and less likely to cause staining or fast filling. Compared with perforations not associated with MAE, perforations associated with MAE were larger in size, more proximal or at collateral location, and had a high-risk shape. When the core lab attributed the perforation to the approach used when the perforation occurred, 61% of retrograde perforations by other classifications were actually antegrade.
CONCLUSIONS
Larger size, proximal or collateral location, and high-risk shapes of a coronary perforation were associated with MAE. Six of 10 perforations occurred with antegrade approaches among patients who had both strategies attempted. These finding will help emerging CTO operators understand high-risk features of the perforation that require treatment and inform future comparisons of retrograde and antegrade complications.
Topics: Aged; Aged, 80 and over; Cardiac Tamponade; Chronic Disease; Coronary Occlusion; Coronary Vessels; Female; Heart Injuries; Hospital Mortality; Humans; Male; Middle Aged; Percutaneous Coronary Intervention; Pericardial Effusion; Prospective Studies; Registries; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; United States
PubMed: 31255554
DOI: 10.1016/j.jcin.2019.05.024 -
Annals of Plastic Surgery Jan 2023Soleus muscle flap can be used in different modifications to reconstruct lower limb defects. It can be proximally based, distally based, island or reversed flow flap....
BACKGROUND
Soleus muscle flap can be used in different modifications to reconstruct lower limb defects. It can be proximally based, distally based, island or reversed flow flap. The first description of the soleus muscle as an island flap supplied by one distal perforator was reported by Yajima et al (Plast Reconstr Surg. 1995;96:1162-1168). However, its use as a propeller flap supplied by the distal perforators and rotated for more than 90 degrees was not described yet.
OBEJECTIVES
The aims of the study are to study the detailed vascular anatomy of the distal perforators of the soleus muscle flap and to demonstrate the applicability of using it as a propeller flap.
PATIENTS AND METHODS
A total number of 42 patients were included in this study. These patients had various distal leg and foot defects. All patients were assessed preoperatively by Doppler study and computed tomography angiography to define the vascular status of the leg. The muscle was raised as a reversed flow flap, based on 1 or more distal perforators and its feeding vessel (posterior tibial artery) after being dissected and divided proximally. The muscle was rotated for more than 90 degrees to reach distal leg defects and approximately 180 degrees to reach the foot defects.
RESULTS
All flaps survived completely with good and durable coverage. The vascularity of the limb was not affected in all patients. There was no functional donor site morbidity.
CONCLUSIONS
The reversed flow hemisoleus muscle flap supplied by the distal perforators and the posterior tibial artery has a great arc of rotation that can cover all distal leg, ankle, and foot defects. Therefore, it can be used as alternative to free flap in lower extremity reconstruction. A new nomenclature is suggested for this flap which is the propeller hemisoleus muscle flap.
Topics: Humans; Plastic Surgery Procedures; Foot; Muscle, Skeletal; Tibial Arteries; Free Tissue Flaps; Perforator Flap; Soft Tissue Injuries
PubMed: 36534105
DOI: 10.1097/SAP.0000000000003365 -
African Journal of Paediatric Surgery :... 2020In our institution, we avoid emergency nighttime appendectomies, instead performing the surgery during daylight hours the following day. We examined whether emergency or...
BACKGROUND
In our institution, we avoid emergency nighttime appendectomies, instead performing the surgery during daylight hours the following day. We examined whether emergency or early appendectomies affect the outcome of patient morbidity.
MATERIALS AND METHODS
Medical records of children treated for appendicitis between 2010 and 2012 were retrospectively reviewed. Outcomes were compared between Group 1, defined as those patients who presented to the hospital during the day and underwent appendectomy on the same day and Group 2, defined as those patients who presented to the hospital at night and underwent appendectomy the next day. Incidences of perforation at surgery, operative time, complications and length of stay were analysed. Cases with perforation were also analysed to determine if the perforations could have been identified preoperatively.
RESULTS
A total of 74 patients met the study criteria, including 41 and 33 in Groups 1 and 2, respectively. There were no significant differences in the incidence of perforation at surgery, operative time, complications and length of stay. A total of nine cases of perforation were identified during surgery, and there were no significant differences in the pre-operative characteristics between perforated and non-perforated cases.
CONCLUSIONS
The results of this study indicate that early appendectomy is safe and did not increase patient morbidity. We, therefore, recommend performing appendectomies in the daytime.
Topics: Appendectomy; Appendicitis; Child; Emergencies; Emergency Service, Hospital; Female; Humans; Japan; Length of Stay; Male; Morbidity; Operative Time; Retrospective Studies; Time Factors
PubMed: 33106449
DOI: 10.4103/ajps.AJPS_122_16 -
European Archives of... Jul 2022Injury or inflammation of the middle ear often results in the persistent tympanic membrane (TM) perforations, leading to conductive hearing loss (HL). However, in some...
PURPOSE
Injury or inflammation of the middle ear often results in the persistent tympanic membrane (TM) perforations, leading to conductive hearing loss (HL). However, in some cases the magnitude of HL exceeds that attributable by the TM perforation alone. The aim of the study is to better understand the effects of location and size of TM perforations on the sound transmission properties of the middle ear.
METHODS
The middle ear transfer functions (METF) of six human temporal bones (TB) were compared before and after perforating the TM at different locations (anterior or posterior lower quadrant) and to different degrees (1 mm, ¼ of the TM, ½ of the TM, and full ablation). The sound-induced velocity of the stapes footplate was measured using single-point laser-Doppler-vibrometry (LDV). The METF were correlated with a Finite Element (FE) model of the middle ear, in which similar alterations were simulated.
RESULTS
The measured and calculated METF showed frequency and perforation size dependent losses at all perforation locations. Starting at low frequencies, the loss expanded to higher frequencies with increased perforation size. In direct comparison, posterior TM perforations affected the transmission properties to a larger degree than anterior perforations. The asymmetry of the TM causes the malleus-incus complex to rotate and results in larger deflections in the posterior TM quadrants than in the anterior TM quadrants. Simulations in the FE model with a sealed cavity show that small perforations lead to a decrease in TM rigidity and thus to an increase in oscillation amplitude of the TM mainly above 1 kHz.
CONCLUSION
Size and location of TM perforations have a characteristic influence on the METF. The correlation of the experimental LDV measurements with an FE model contributes to a better understanding of the pathologic mechanisms of middle-ear diseases. If small perforations with significant HL are observed in daily clinical practice, additional middle ear pathologies should be considered. Further investigations on the loss of TM pretension due to perforations may be informative.
Topics: Ear, Middle; Hearing Loss, Conductive; Humans; Stapes; Tympanic Membrane; Tympanic Membrane Perforation
PubMed: 34570265
DOI: 10.1007/s00405-021-07078-9 -
Stroke Nov 2022Despite advances in understanding various risk and prognostic factors, spontaneous intracerebral hemorrhage is connected to very high morbidity and mortality, while the...
BACKGROUND
Despite advances in understanding various risk and prognostic factors, spontaneous intracerebral hemorrhage is connected to very high morbidity and mortality, while the therapy is mainly supportive. Understanding of the pathophysiology of initial hematoma expansion is limited due to insufficient clinical data and lack of a suitable animal model.
METHODS
We injected 40 anatomic specimens of the basal ganglia with contrast medium, scanned them with a micro-computed tomography scanner and analyzed the results of radiological studies, direct and histological examinations.
RESULTS
In 9 cases, micro-computed tomography and histological examinations revealed contrast medium extravasations mimicking intracerebral hematomas. The artificial hematomas spread both proximally and distally along the ruptured perforator and its branches in the perivascular spaces and detached the branches from the adjacent neural tissue leading to destruction of the tissue and secondary extravasations. Moreover, some contrast extravasations skipped to the perivascular spaces of unruptured perforators, created further extravasation sites and aggravated the expansion of the artificial hematoma. There was no subarachnoid extension of any artificial hematoma.
CONCLUSIONS
We postulate that a forming basal ganglia intracerebral hematoma spreads initially in the perivascular space, detaches the branches from the neural tissue and causes secondary bleeding. It can also skip to the perivascular space of a nearby perforator. The proposed mechanism of hematoma initiation and formation explains extent of damage to the neural tissue, variability of growth in time and space, creation of secondary bleeding sites, and limited usefulness of surgical interventions. The model is reproducible, the extent of the artificial hematoma can be easily controlled, the rupture sites of the perforating arteries can be determined, and preparation of the model does not require specialized, expensive equipment apart from the micro-computed tomography scanner.
Topics: Animals; X-Ray Microtomography; Cerebral Hemorrhage; Hematoma; Contrast Media; Basal Ganglia
PubMed: 36073367
DOI: 10.1161/STROKEAHA.122.040143 -
Cardiovascular Diagnosis and Therapy Aug 2019Perforator flap-based breast reconstruction in a post mastectomy patient requires dissection of the artery-vein bundle (perforators) responsible for perfusion of the... (Review)
Review
Perforator flap-based breast reconstruction in a post mastectomy patient requires dissection of the artery-vein bundle (perforators) responsible for perfusion of the subcutaneous fat and skin of the flap. Traditionally, these reconstructions were performed with the transverse rectus abdominis myocutaneous (TRAM) flap, but autologous breast reconstruction using muscle sparing free flaps has become steadily more popular in recent years. Preoperative imaging to locate and evaluate candidate perforators has become an essential step before patients undergo the microsurgical procedure. Preoperative mapping assists with operative planning, reduces operating times, and brings anatomical variations to their attention. Pre-operative imaging also assists in choosing the appropriate donor site for harvesting flaps. Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) have been widely used for this type of preoperative imaging. Both MRA and CTA have their inherent advantages and disadvantages, and the preferred modality for this purpose varies by institution based on factors such as scanner availability, radiologist and surgeon experience, and comfort in interpreting the images. Concerns over excessive exposure to ionizing radiation and poor iodinated contrast agent enhancement of the intramuscular perforator course has made MRA the first-choice imaging modality in many centers. The purpose of the article is to review technique and protocols for the pre-operative CTA/MRA in patients who are being considered for a deep inferior epigastric artery perforator (DIEP) or profunda artery perforator (PAP) flap and to familiarize the reader with the normal and variant anatomic features of the deep inferior epigastric and PAP vessels along with the anatomic and surgical considerations used in the selection of perforator flap donor site for breast reconstruction post mastectomy.
PubMed: 31559159
DOI: 10.21037/cdt.2018.10.03 -
Alternative Therapies in Health and... Apr 2023The most common cause of hearing loss is chronic otitis media. Patients often exhibit ear tightness, ear plugging, conductive hearing loss, and even secondary...
CONTEXT
The most common cause of hearing loss is chronic otitis media. Patients often exhibit ear tightness, ear plugging, conductive hearing loss, and even secondary perforation of the tympanic membrane. Patients require antibiotics to improve symptoms, and some patients need surgical repair of the membrane.
OBJECTIVE
The study intended to examine the effects of two methods of surgical transplantation using porcine mesentery under an otoscope on the surgical outcomes of patients with tympanic-membrane perforation secondary to chronic otitis media, with the intent to provide a basis for clinical practice.
DESIGN
The research team conducted a retrospective case-controlled study.
SETTING
The study took place at the Sir Run Run Shaw Hospital of the College of Medicine at Zhejiang University in Hangzhou, Zhejiang, China.
PARTICIPANTS
Participants were 120 patients with tympanic membrane perforations that were secondary to chronic otitis media who had been admitted to the hospital between December 2017 and July 2019.
INTERVENTION
The research team divided the participants into two groups according to the surgical indications for repair of their perforations: (1) for patients with the central type of perforations with a rich residual tympanic membrane, the surgeon used the internal implantation method, and (2) for patients with a marginal or central perforation with a low residual tympanic membrane, the surgeon used the interlayer implantation method. Both groups received the implantations under conventional microscopic tympanoplasty, and the Department of Otolaryngology Head & Neck Surgery at the hospital provided the porcine mesenteric material.
OUTCOME MEASURES
The research team compared the differences between the groups in operation time, blood loss, changes in the level of hearing loss between baseline and postintervention, air-bone conductivity, treatment effects, and surgical complications.
RESULTS
The operation time and blood loss of the internal implantation group were significantly greater than those of interlayer implantation group (P < .05). At 12 months postintervention, one participant in the internal implantation group had perforation recurrence, and two participants in the interlayer implantation group had infections and two had perforation recurrence. No significant difference existed between the groups in the complication rate (P > .05).
CONCLUSIONS
Endoscopic repair of tympanic membrane perforations that were secondary to chronic otitis media, using porcine mesentery as the material for implantation, is a reliable treatment with few complications and good postoperative hearing recovery.
Topics: Humans; Swine; Animals; Tympanic Membrane; Retrospective Studies; Treatment Outcome; Tympanic Membrane Perforation; Otitis Media; Hearing Loss; Chronic Disease; Intestine, Small
PubMed: 36795519
DOI: No ID Found -
Graefe's Archive For Clinical and... Jul 2023The following is a comparative analysis on the treatment outcomes of corneal perforations using amniotic membrane transplantation (AMT) or penetrating keratoplasty (PK).
PURPOSE
The following is a comparative analysis on the treatment outcomes of corneal perforations using amniotic membrane transplantation (AMT) or penetrating keratoplasty (PK).
METHODS
This monocentric retrospective study was performed at the Department of Ophthalmology, University Hospital Ulm, Germany. A total of 78 eyes of 78 patients were included. Thirty-nine eyes received an AMT, and 39 patients were treated with a PK. Primary outcome was recurrence of perforation. Secondary outcomes were patient mortality and visual acuity.
RESULTS
No statistically significant difference was observed with regard to a recurrence of perforation between the two groups (26% in AMT vs 23% in PK, p > 0.99). The time of recurrences was within the first two years and did not differ statistically (p = 0.97). In addition, a proportional hazards model with cox regression regarding recurrent perforation showed no significant differences (p = 0.5). After AMT, 41% and after KP, 28% of the patients died during follow-up (p = 0.2), respectively. The Charlson Comorbidity Index (p < 0.0001) and the age at the time of surgery (p = 0.0002) were statistically significantly higher in those who were deceased. A mean follow-up of 485 ± 517 days was recorded.
CONCLUSION
Both surgical methods show good results and no statistically significant difference regarding recurrent perforation rate. About a third of the patients died during the follow-up period. The decision regarding the appropriate method should therefore be based on a combination of all factors.
Topics: Humans; Keratoplasty, Penetrating; Corneal Perforation; Amnion; Retrospective Studies; Treatment Outcome; Corneal Transplantation; Corneal Diseases
PubMed: 36680612
DOI: 10.1007/s00417-022-05914-0 -
BMJ Case Reports Mar 2020A 49-year-old man presented to the nearest emergency department profoundly septic with significantly raised inflammatory markers. He had a background of floor of mouth...
A 49-year-old man presented to the nearest emergency department profoundly septic with significantly raised inflammatory markers. He had a background of floor of mouth invasive squamous cell carcinoma for which he underwent complex head and neck surgery followed by adjuvant radiotherapy and insertion of a percutaneous gastrostomy tube for feeding. He experienced 3 weeks of retching, cough and malaise. Imaging revealed both an oesophageal perforation and perforated duodenal ulcer, presumed secondary to oesophageal stricturing from his prior surgery and radiotherapy.
Topics: Adult; Diagnosis, Differential; Duodenal Ulcer; Enteral Nutrition; Esophageal Perforation; Gastrostomy; Humans; Laparotomy; Male; Mouth Neoplasms; Peptic Ulcer Perforation; Squamous Cell Carcinoma of Head and Neck
PubMed: 32198227
DOI: 10.1136/bcr-2019-233658 -
Clinical Endoscopy Jan 2020Colon perforations are difficult to resolve because they occur unexpectedly and infrequently. If the clinician is unprepared or lacks training in dealing with...
Colon perforations are difficult to resolve because they occur unexpectedly and infrequently. If the clinician is unprepared or lacks training in dealing with perforations, the clinical prognosis will be affected, which can lead to legal issues. We describe here the proper approach to the management of perforations, including deciding on endoscopic or surgical treatment, selection of endoscopic devices, endoscopic closure procedures, and general management of perforations that occur during diagnostic or therapeutic colonoscopy.
PubMed: 31266269
DOI: 10.5946/ce.2019.061