Andreas Gravvanis

Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: A prospective randomized study*

Objective:Subclavian vein catheterization may cause various complications. We compared the real-time ultrasound-guided subclavian vein cannulation vs. the landmark method in critical care patients. Design:Prospective randomized study. Setting:Medical intensive care unit of a tertiary medical center. Patients:Four hundred sixty-three mechanically ventilated patients enrolled in a randomized controlled ISRCTN-registered trial (ISRCTN-61258470). Interventions:We compared the ultrasound-guided subclavian vein cannulation (200 patients) vs. the landmark method (201 patients) using an infraclavicular needle insertion point in all cases. Catheterization was performed under nonemergency conditions in the intensive care unit. Randomization was performed by means of a computer-generated random-numbers table and patients were stratified with regard to age, gender, and body mass index. Measurements and Main Results:No significant differences in the presence of risk factors for difficult cannulation between the two groups of patients were recorded. Subclavian vein cannulation was achieved in 100% of patients in the ultrasound group as compared with 87.5% in the landmark one (p < .05). Average access time and number of attempts were significantly reduced in the ultrasound group of patients compared with the landmark group (p < .05). In the landmark group, artery puncture and hematoma occurred in 5.4% of patients, respectively, hemothorax in 4.4%, pneumothorax in 4.9%, brachial plexus injury in 2.9%, phrenic nerve injury in 1.5%, and cardiac tamponade in 0.5%, which were all increased compared with the ultrasound group (p < .05). Catheter misplacements did not differ between groups. In this study, the real-time ultrasound method was rated on a semiquantitative scale as technically difficult by the participating physicians. Conclusions:The present data suggested that ultrasound-guided cannulation of the subclavian vein in critical care patients is superior to the landmark method and should be the method of choice in these patients.

Percutaneous versus Conventional Tracheostomy in Burned Patients with Inhalation Injury.

The aim of the study was to compare conventional tracheostomy with percutaneous dilatational tracheostomy in patients with inhalation burn injury. A total of 37 patients with severe burn injuries and associated inhalation injury, underwent percutaneous tracheostomy in our burn unit and were retrospectively compared with 22 patients who underwent conventional surgical tracheostomy. In the first group, 25 of 37 patients and in the second group 17 of 22 patients presented with partial or full-thickness burn injuries (or both) in the neck region. The cost of the procedure, operating time, complications, and incidence of pulmonary infection were recorded. There were no significant perioperative complications in the percutaneous tracheostomy group, and no patient required surgical revision or conversion to surgical tracheostomy. In the conventional tracheostomy group, 2 patients developed tracheal stenosis, 1 had a tracheoesophageal fistula, and 10 had stomal infections. The average procedure time in the first group was 9 minutes, and in the second group it was 22 minutes. The cost of the bedside percutaneous tracheostomy was one-fifth the cost of a conventional tracheostomy. The incidence of pulmonary sepsis was 45% after percutaneous tracheostomy compared to 68% after conventional tracheostomy. With the percutaneous technique, spontaneous closure of the stoma occurred within 1 to 3 days after removal of the tracheostomy tube, whereas with the conventional technique it was within 5 to 7 days. Percutaneous tracheostomy is associated with a lower complication rate and can be safely performed at the bedside. Moreover, it is faster and can be done at a lower cost than conventional open tracheostomy.

The use of Integra artificial dermis to minimize donor-site morbidity after suprafascial or subfascial dissection of the radial forearm flap.

We read with great interest the article entitled ‘‘Reconstruction of the Radial Forearm Free Flap Donor Site Using Integra Artificial Dermis’’ by Murray et al. The authors following suprafascial dissection of a free radial forearm flap, they provided coverage of the donor site with Integra artificial dermis, reporting negligible donor site complications, excellent cosmesis, and minimal scar contracture. These results are consistent with our study, which showed that suprafascial dissection of the forearm flap creates a superior graft recipient site for the Integra artificial dermis, resulting in an excellent functional and aesthetic outcome. Given that the suprafascial is considered technically more demanding compared to the conventional subfascial dissection, a reasonable issue is raised: is the artificial dermis able to ensure minimal donor-site morbidity without the aid of the suprafascial technique? Aiming to answer this question, we assessed the donor site morbidity after subfascial harvesting of the radial forearm flap and coverage with Integra artificial dermis, in four patients who underwent partial glossectomy reconstruction. The flaps were dissected subfascially intending to give more bulk to the reconstructed tongue. A dorsal support splint was applied and gentle physiotherapy commenced the first postoperative day. Complete take of the Integra was recorded, the splint was removed, and the full range of motion was allowed. A split-thickness skin graft was applied over the newly formed neodermal tissue, 14–18 days later (Fig. 1). To evaluate donor site morbidity, we have applied the same methodology as previously reported. All patients were evaluated for wrist and fingers’ range of motion, grip power, and pulp-to-pulp pinch power (follow-up ranging 9–12 months). The size of the donor site defect was recorded and compared with the final size of the donor site at the end of the follow-up. Wound healing with complete take, both of Integra artificial dermis and skin graft was recorded in all patients. No tendon adhesion was noted whereas normal range of motion of the wrist and fingers was documented. Sensibility of donor forearms was normal at the end of follow-up; with no incidence of cold intolerance, paresthesia or pain. These results are equivalent to the previously reported studies, indicating that Integra is able to ensure minimal donor site morbidity after subfascial dissection as well. All patients judged the esthetic appearance as satisfactory. The postoperative dimensions of the donor site merit scrupulous interpretation. Although Murray et al. did not comment on the size of donor defect, they noted exuberant granulation in 19% of cases and was attributed to the longer duration of Integra grafting. Comparing our findings, in the cases of the suprafascial dissection the donor area was remarkably decreased (Fig. 2), whilst in the cases of subfascial dissection the donor site defect remained almost at the original size (Fig. 1). Greater amount of granulation tissue was evident after the removal of the silicone sheath in the cases of the suprafascial dissection (Fig. 2). According to the cell contraction theory, myofibroplasts within the granulation tissue contract and in doing so pull on collagen *Correspondence to: Andreas Gravvanis, M.D., Ph.D., FEBOPRAS, Patroklou 10, Agia Paraskevi, 15343, Athens, Greece. E-mail: gravvani@yahoo.com

Blood perfusion of the free anterolateral thigh perforator flap: its beneficial effect in the reconstruction of infected wounds in the lower extremity.

BackgroundIn a prospective study, we evaluated the blood perfusion and the blood flow of anterolateral thigh (ALT) flap by both near-infrared spectroscopy and color Doppler ultrasonography. Moreover, we assessed the ability of the perforator flap to reconstruct infected wounds of the lower extremity in 11 patients.MethodsNear-infrared spectroscopy showed excellent oxygen saturation, and Doppler ultrasonography documented excellent blood flow and decreased vascular resistance in the ALT flap postoperatively.ResultsAll flaps were successful and all wounds healed uneventfully within 2 weeks without any signs of recurrences or persistent infection. All patients achieved acceptable gait function after rehabilitation.ConclusionsApart from the mandatory role of thorough debridement, our results indicate that the ALT flap offers rich blood supply to the recipient area, thus contributing to the sterilization and healing of an infected wound within a short time period.

Foucher first dorsal metacarpal artery flap versus littler heterodigital neurovascular flap in resurfacing thumb pulp loss defects.

Our study aims to illustrate the advantages and disadvantages of Fouchers first dorsal metacarpal artery flap and Littlers heterodigital neurovascular flap in thumb pulp reconstruction, by assessing wound healing of donor and recipient sites, sensibility, and functional outcome of the reconstructed thumb. Fourteen male patients were reconstructed either with Foucher (n = 8) or Littler flap (n = 6). Dissection of Fouchers flap was faster than that of Littlers flap. All Littler flaps survived completely, but we experienced 1 partial Foucher flap necrosis. Thumb motility and stability was optimal in all patients. Wound healing of donor sites was achieved in both groups. Two patients reconstructed with Littler flap developed scar contractures and presented a reduced range of motion of donor finger and first webspace, respectively. Although Littler flap resulted in better sensibility and tactile gnosis of the reconstructed thumb-pulp, Foucher flap ensured negligible donor site morbidity, complete cortical reorientation, and better overall hand function.

Burned Breast Reconstruction by Expanded Artificial Dermal Substitute

Full-thickness anterior chest wall burns result in contractures that may restrict the development of breast in young female patients. The management of postburn contractured anterior chest wall scars and unilateral breast hypoplasia with the expansion of bilayered artificial skin is herein presented for the first time in literature to the best of our knowledge. A 21-year-old female with chest wall contractures after thermal injury she had suffered at the age of 27 months was managed in three stages. The first stage included release and excision of contractures and scars, submuscular insertion of anatomical tissue expander, and coverage of the anterior chest wall with Integra artificial skin (Skin, Johnson & Johnson Medical, Division of Ethicon, Inc., Sommerville, NJ). One month later, the outer silicone layer of Integra was substituted by a split-thickness skin autograft and the expander was partly inflated with saline. During the third stage and after overexpansion of the expander had been completed, the expander was removed and a permanent silicone implant was subsequently inserted. No immediate or late complications were observed. At 17 months, the breast contour remains stable, no recontracture has occurred, and the patient evaluates the result as very satisfactory. Expansion of artificial skin Integra appears to be a reliable and safe alternative for reconstruction of the burned breast, lacking the morbidity associated with deep donor sites of full-thickness skin autografts or flaps.

Dermal skin template for the management of multiple cutaneous leiomyomas.

Background: Multiple leiomyomas are rare benign tumors of the skin, originating from the arrector pili muscle, and usually appear as painful nodules. Several pharmacologic agents have been used with some success to reduce pain and discomfort since surgery may be an impractical approach owing to the extent of the disease. Objective: This article reports on a patient with multiple cutaneous leiomyomas of the upper limb who was managed by a method not previously reported for leiomyomas. Method: The management involved total surgical resection of the defect and immediate reconstruction with the Integra artificial dermal template (Integra LifeSciences Corp., Plainsboro, NJ). Results: With this treatment, the patient was totally relieved from the pain, and optimal functional and esthetic results were achieved. Conclusion: Complete surgical resection of multiple cutaneous leiomyomas prevented the diseases recurrence. The immediate reconstruction of the resultant full-thickness defect with artificial dermis ensured uneventful wound healing, resulting in optimal functional and esthetic outcome and total relief from leiomyoma-associated discomfort.

Venous augmentation of distally based pedicled ALT flap to reconstruct the tibial tuberosity in a severely injured leg.

The exposed tibial tuberosity poses a challenge to the reconstructive surgeon. A well-vascularized tissue is necessary to ensure wound healing and to facilitate any concomitant orthopedic procedure. Use of the gastrocnemius, soleus muscle flap, and sural artery perforator flap has been proved to be effective in the management of these defects. However, in the severely damaged lower limb, a distant flap is often a better and safer choice, since it avoids further incisions to the injured area and introduces arterial perfusion from an uninjured proximal source, facilitating wound healing. The use of a free flap is not always a straightforward procedure for this particular area, due to the difficulties in recipient vessel selection positioned deeply around the knee. We have previously demonstrated the use of the distally based pedicled ALT flap to reconstruct the exposed knee joint as a safe, effective, and reproducible procedure. Other authors have also reported this procedure for knee reconstruction, pointing out the advantages of this flap such as a long pedicle length, a sufficient tissue supply, possible combination with fascia lata for tendon reconstruction, and favorable donor-site selection. On the other hand, questionable arterial supply and problems of venous congestion have been reported. We present the successful use of a distally based pedicled anterolateral thigh flap with a venous supercharge, to reconstruct the tibial tuberosity in a severely injured lower limb.

Changes in arterial blood flow of free flaps after the administration of sildenafil in swine

We evaluated blood flow changes after experimental free tissue transfer and the potential hemodynamic effect of sildenafil on the free flap. Sixteen swine were used for free transfer of a latissimus dorsi myocutaneous flap to the chest that was anastomosed to the internal mammary vessels, and were randomized into controls and study group. The latter received a single dose of sildenafil, 6 hours following flap revascularization. Doppler ultrasonography revealed that arterial flow was mainly systolic postoperatively. Diastolic flow patterns were gradually restored after the first postoperative day. Pulsatility index (PI) significantly increased and flow volume decreased in all animals postoperatively. In the sildenafil group, PI significantly decreased and flow volume increased, while diastolic flow patterns were restored earlier on compared to controls, postoperatively. In conclusion, the administration of sildenafil after free tissue transfer increases flow volume and facilitates the restoration of diastolic blood flow patterns in the early critical postoperative period.

Impact of portable duplex ultrasonography in head and neck reconstruction.

Abstract We have reviewed the use of portable duplex ultrasonography (PDU) in 12 patients who underwent soft tissue/bone head and neck reconstruction, aiming to determine its role in the design and management of such complex cases. According to our data, there were modifications either of the surgical plan or of patient’s management, based on PDU findings, in 9 (75%) of 12 patients. The use of ultrasound directed to subtle modifications in 3 patients (25%) but to significant changes of the surgical plan in the other 3 patients (25%). Also, the use of duplex ultrasound impacted significantly the postoperative management in 4 patients (33.33%). Thus, significant impact of PDU in patient’s treatment was recorded in 58.33% of cases. Portable ultrasound represents generally available method for preoperative, intraoperative, and postoperative diagnosis and decision making in free tissue transfer, hence could replace in the future the unidirectional Doppler in the hands of head and neck surgeons.