Peter Henderson

Endoluminal recanalization in a patient with phlegmasia cerulea dolens using a multimodality approach-a case report.

Phlegmasia cerulea dolens is a limb-threatening form of deep venous thrombosis and should be treated aggressively. The authors report a patient who presented with iliocaval and femoral deep venous thrombosis and posed an additional therapeutic challenge based on a recent history of heparin-induced thrombocytopenia. Catheter-directed pharmacologic thrombolysis and balloon venoplasty were applied in treatment. The direct thrombin inhibitor argatroban was used in place of heparin for concurrent anticoagulation. This multimodality endovascular approach (chemical and mechanical interventions) was successful in relieving the venous occlusion and salvaging the limb, while maintaining appropriate treatment for heparin-induced thrombocytopenia.

Single Institution Experience with Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) for the Primary Prevention of Lymphedema

BackgroundAs many as 40xa0% of breast cancer patients undergoing axillary lymph node dissection (ALND) and radiotherapy develop lymphedema. We report our experience performing lymphatic–venous anastomosis using the lymphatic microsurgical preventive healing approach (LYMPHA) at the time of ALND. This technique was described by Boccardo, Campisi in 2009.MethodsLYMPHA was offered to node-positive women with breast cancer requiring ALND. Afferent lymphatic vessels, identified by injection of blue dye in the ipsilateral arm, were sutured into a branch of the axillary vein distal to a competent valve. Follow-up was with pre- and postoperative lymphoscintigraphy, arm measurements, and (L-Dex®) bioimpedance spectroscopy.ResultsOver 26xa0months, 37 women underwent attempted LYMPHA, with successful completion in 27. Unsuccessful attempts were due to lack of a suitable vein (nxa0=xa03) and lymphatic (nxa0=xa05) or extensive axillary disease (nxa0=xa01). There were no LYMPHA-related complications. Mean follow-up time was 6xa0months (range 3–24xa0months). Among completed patients, 10 (37xa0%) had a body mass index of ≥30xa0kg/m2 (mean 27.9xa0±xa06.8xa0kg/m2, range 17.4–47.6xa0kg/m2), and 17 (63xa0%) received axillary radiotherapy. Excluding two patients with preoperative lymphedema and those with less than 3-month follow-up, the lymphedema rate was 3 (12.5xa0%) of 24 in successfully completed and 4 (50xa0%) of 8 in unsuccessfully treated patients.ConclusionsOur transient lymphedema rate in this high-risk cohort of patients was 12.5xa0%. Early data show that LYMPHA is feasible, safe, and effective for the primary prevention of breast cancer-related lymphedema.

Postcarotid Endarterectomy Pseudoaneurysm Treated with Combined Stent Graft and Coil Embolization A Case Report

Pseudoaneurysm formation is a rare complication following carotid endarterectomy (CEA); however, its occurrence is associated with significant risk of morbidity. The patient in this report presented 2 years following CEA with headache and lateral neck mass. The diagnosis of a 3.5 x 3.0 cm carotid artery bifurcation pseudoaneurysm was made by using magnetic resonance angiography (MRA). Endovascular exclusion of the aneurysm was accomplished with coil embolization of the external carotid artery followed by deployment of a 7 x 50 mm wall stent graft into the common carotid artery-internal carotid artery (CCA-ICA). The patients symptoms improved and at 6-months postexclusion, duplex ultrasound demonstrated a significant reduction in pseudoaneurysm size. This case highlights the feasibility and safety of using endovascular techniques in the treatment of post-CEA pseudoaneurysm.

Update on the Diagnosis and Management of Popliteal Aneurysm and Literature Review

Popliteal artery aneurysms (PAAs) are the most frequent peripheral aneurysm with a significant morbidity if left untreated. Open surgical technique is still considered the gold standard; however the revolution in endovascular repair has proven to be a valid alternative option in selected patients. The role of endovascular treatment in PAA is still considered in its infancy. In addition, the indications for use of endovascular stents as compared to standard open surgery have not yet been fully defined and more studies are warranted to characterize the durability of this technique. This article describes the general principles of the natural history, clinical presentation, and long-term limb salvage and survival outcomes for patients with such aneurysms. It also details the features and results for the devices in current use and highlights the current consensus in the management of PAA.

Rupture of Excluded Popliteal Artery Aneurysm: Implications for Type II Endoleaks A Case Report

The fate of popliteal artery aneurysms after ligation and bypass is believed to be relatively innocuous. The patient presented in this report, however, experienced spontaneous rupture of a popliteal aneurysm 11 years after ligation and bypass. Magnetic resonance angiography was used to establish the diagnosis of rupture, which was subsequently confirmed at surgery. Intraoperative arteriography demonstrated persistent collateral arterial perfusion of the excluded popliteal aneurysm sac. The collateral arterial flow originated from the superior and inferior lateral genicular arteries. The persistent arterial perfusion resulted in growth of the aneurysm from 4.2 to 7.0 cm over the 11-year period. The ruptured aneurysm was successfully treated by direct arterial exposure and suture ligation of the collateral vessels performed from within the aneurysm sac. The development of popliteal aneurysm expansion and rupture as a result of collateral arterial perfusion suggests that persistent collateral perfusion of abdominal aortic aneurysms after endovascular repair (type II endoleak) may lead to aneurysm rupture. Therefore, close observation and intervention for aneurysm expansion to prevent rupture of the excluded aneurysm are warranted.

Fusogens: chemical agents that can rapidly restore function after nerve injury

BACKGROUNDnRestoring function after nerve injury remains one of medicines greatest challenges. The current approach of epineurial coaptation does not address the fundamental insult at the molecular level: a discontinuity in the axonal membranes. Membrane fusion is possible through agents collectively called chemical fusogens, which are heterogeneous in structure and mechanism of action. We sought a unifying system for classifying fusogens to better understand their role in cell fusion.nnnMATERIALS AND METHODSnWe conducted a comprehensive literature review to identify the most commonly cited chemical fusogens, their structures, mechanisms of actions, and clinical applications to date. We identified seven chemical fusogens (polyethylene glycol, chitosan, dextran sulfate, n-nonyl bromide, calcium, sodium nitrate, and H-α-7), which have each been studied to different extents in protoplasts, animals, and humans.nnnRESULTSnChemical fusogens achieve cell fusion by one of two ways: bringing cells in close enough proximity to each other so the inherent fluidity of the phospholipid membrane allows for their rearrangement or modifying the surface charges of the membranes to diminish repellent charges. Sowers initially put forth a classification system that identified these agents as cell aggregators and membrane modifiers, respectively. We adapted this classification system in the setting of axonal membrane fusion and hypothesized that the most effective approach to axonal membrane repair is likely combination of both.nnnCONCLUSIONSnChemical fusogens could be grouped into two mechanistic categories-cell aggregators and membrane modifiers. For axonal membrane fusion, a combination of both mechanisms can significantly contribute to advancing outcomes in peripheral nerve repair via a chemical-surgical intervention.

Technical Tip: Mark Scarpaʼs Fascia to Facilitate Proper Abdominal Closure During Autologous Breast Reconstruction

1 T of the main objectives of closure of the abdominal defect during autologous breast reconstruction are to maximize strength of the wound and to optimize scar appearance by reducing tension at the level of the dermis. One technical element that achieves both of these goals, and is therefore commonly utilized, is closure of Scarpa’s (superficial abdominal) fascia (SF) as a separate, strengthbearing layer.1 Unfortunately, SF can be difficult to identify (especially for trainees), and inaccurate identification of SF can lead to suboptimal clinical outcomes: inclusion of excessive amounts of subcutaneous fat in an attempt to “not miss” SF can lead to fat necrosis and its undesired sequelae,2 and inadvertent failure to include SF in the closure can lead to a widened scar and sometimes even incisional dehiscence. There are multiple factors that increase the likelihood of incorrect identification of SF during abdominal tissue–based breast reconstruction: for instance, patients who undergo autologous breast reconstruction often have large amounts of subcutaneous fat and therefore SF is particularly difficult to visualize, and the common practice of placing temporary staples that facilitate appropriate alignment in the left-to-right direction makes visualization of SF even more difficult. To decrease uncertainty regarding the exact location of SF, we have developed a simple, fast, no-cost method that facilitates reliability-effective closure of SF. After hemostasis has been confirmed and all irrigation has been completed, a surgical marking pen is used to mark the exact location of SF on both the cranial and caudal flaps (Fig. 1). Once this has been done, temporary alignment staples can be placed, and while one team completes the chest portion of the procedure, the abdominal defect is closed effectively and rapidly because the uncertainty of the location of SF has been eliminated (Fig. 2). This simple intervention has been met with enthusiasm—and a sense of relief—by the members of the surgical team at our center, and we encourage those at other centers to consider adoption of this technique, as well. Peter W. Henderson, MD, MBA Plastic and Reconstructive Surgery Service Department of Surgery Memorial Sloan Kettering Cancer Center 1275 York Avenue MRI 1007 New York, NY 10065 E-mail: hendersp@mskcc.org

Immediate and complete restoration of peripheral nerve function after injury is attainable by a combination of surgical and chemical interventions

Despite significant advances in almost every other aspect of medicine, physicians are still unable to restore function after nerve injury with any consistency or reliability. The current standard of care (which involves coaptation of the two ends via epineurial sutures) is largely unchanged from its first description over 400u202fyears ago, and unfortunately leads to a recovery that is at best slow (taking months or years) and partial. Encouragingly, two new conceptual approaches are being developed that separately have been shown to improve outcomes. The first approach involves optimization of the mechanical aspects of nerve coaptation (with an emphasis on exceedingly clean cuts of the axon ends and moving any suture material far away from the coaptation site). The second approach involves manipulation of the chemical composition of the local environment at the cut ends of the nerve in order to promote re-establishment of membranous continuity. Though neither approach currently leads to results that reach those of uninjured controls, there is reason to believe that these two approaches can be used concurrently. Thus, we hypothesize that immediate and complete restoration of peripheral nerve function after injury is attainable by a combination of surgical and chemical interventions. The combination could be tested in rodents and non-human primates by assessing histology, electrical activity, intracellular diffusion, and functional status and could likely rapidly move to a clinical trial in humans. If the hypothesis is proven to be true, its impact would be profound, as it would positively affect not only recovery after traumatic nerve injury, but also functional status after allotransplantation, as well as introduce the prospects of advanced interfaces between human nerves and computer circuits.