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PubMed2006

Epifascial accessory palmaris longus muscle.

In hand reconstructive surgery the palmaris longus muscle is one of the most utilized donor site for tendon reconstruction procedures. However, its anatomic position is variable and anatomic variations may be responsible for median nerve compression. We report the case of a 40-year-old, right-handed woman, who presented with numbness and paresthesias in the palm and in the flexor aspect of the first, second, and third fingers of her right hand for the preceding 5 months, coinciding with increase of office work (typing). The clinical examination and radiological investigations (ultrasound and magnetic resonance) revealed a subcutaneous mass (15 mm x 2.3 mm x 6 cm), with a lenticular shape and definite edges at the level of the volar aspect of the distal third of the forearm. The fine-needle aspiration biopsy revealed the presence of striated muscle fibers. During surgery, a muscle belly was found in the epifascial plane. This muscle originated from subcutaneous septa in the middle forearm and inserted on to the superficial palmar aponeurosis with fine short tendon fibers. Exposure of the antebrachial fascia did not reveal any area of weakness or muscle herniation. The palmaris longus tendon, flexor digitorum superficialis tendons, and flexor carpi radialis tendon showed usual topography under the antebrachial fascia. The accessory muscle was excised and histology revealed unremarkable striated muscle fibers, limited by a thin connective sheath. The presence of an accessory palmaris longus (APL) located in the epifascial plane could be ascribed to an unusual migration of myoblasts during the morphogenesis. Although extremely rare, APL is worth bearing in mind as a possible cause of median nerve compression and etiology of a volar mass in the distal forearm.

Adult↗

PubMed1978

Anomalous origin of the right coronary artery above the left sinus of Valsalva.

Various anomalies of coronary arterial origin have been described. These anatomical variations are discovered either by coronary angiography or at autopsy. We are reporting a case of anomalous origin of the right coronary artery above the left sinus of Valsalva. To our knowledge, this anomaly has not been described before. A technique for selectively catheterizing such an aberrant coronary artery is described.

Aged↗

PubMed1988

Percutaneous transluminal angioplasty for shepherd's crook right coronary artery stenosis.

Angiograms from 1,043 consecutive patients undergoing right coronary artery angioplasty were reviewed to determine the incidence of "shepherd's crook" origin of the right coronary artery. Primary results, complications, and technical difficulties were compared with a control group. Fifty-one patients (4.9%) were found to have this anatomic variation. Compared with a control group, the primary success rate was lower (86% vs. 98%) and the incidence of procedural difficulties was higher (33% vs. 13%). Technical problems led to the use of more guiding catheters and more guidewires per patient than in the control group. Thus, coronary angioplasty of shepherd's crook right coronary artery imposes technical problems and is associated with less than an optimal primary success rate.

Angiography↗

PubMed2006

Initial transcatheter palliation of hypoplastic left heart syndrome.

Initial percutaneous transcatheter palliation of hypoplastic left heart syndrome is now feasible. The primary procedures for palliation include stenting of the ductus arteriosus with a self expanding nitinol stent to secure an adequate systemic blood flow, placement of an internal pulmonary arterial band to protect the pulmonary vascular bed and to prevent pulmonary overcirculation, and widening of the interatrial communication by blade and balloon septostomy or static balloon dilation to decompress the left atrium. Anatomic variations of the ductus arteriosus have important implications for technical success with ductal stenting. Patients who have undergone complete transcatheter palliation with the internal pulmonary band appear to have less immediate morbidity at the time of transplant, with preserved integrity and growth of the branch pulmonary arteries at one year follow-up.

Blood Flow Velocity↗

PubMed2007

Repeat right transradial percutaneous coronary intervention in a patient with dextrocardia: the right approach to the right-sided heart.

Dextrocardia (DC) is a rare cardiac condition in which the cardiac location, as well as apex, is rightwardly displaced. As the incidence of atherosclerotic disease is similar to that of the general population, there have been few reports of percutaneous coronary interventions (PCIs) in these patients. Proposed technical strategies for successful angiography and PCI in DC include counter-directional torquing of the catheter, as well as right-left mirror-image inversion angiographic views. All previous reports of DC PCIs have been via transfemoral access.We present a case of successful repeat transradial PCI in a patient with DC. This is first report of transradial coronary angiography, PCI, or repeat PCI in a DC patient. A literature review of technical considerations, including our own recommendations for guide catheter selection, are discussed. We also review the anatomic variations and epidemiology of DC. Although access complications for transradial PCI is known to be lower than that of the transfemoral approach, challenges in technique and concern of repeat access have limited the popularity of the former. Our report demonstrates the safety and feasibility of transradial angiography, PCI, and even repeat PCI, in the rare patient with DC.

Coronary Angiography↗

PubMed2007

Transradial approach for carotid artery stenting: a feasibility study.

BACKGROUND: Carotid artery stenting (CAS) has become accepted as an alternative to carotid endarterectomy for revascularization of the internal carotid artery (ICA) among high risk patients. CAS from the femoral approach can be problematic due to access site complications as well as technical difficulties related to peripheral vascular disease (PVD) and/or anatomical variations of the aortic arch. The purpose of the present study is to evaluate the feasibility of the radial artery as an alternative approach for CAS. METHODS: Forty-two patients (mean age 71 +/- 1, 26 male) underwent CAS. All had a CA stenosis greater than 80% and comorbid conditions increasing the risk of carotid endarterectomy. The target common carotid artery (CCA) was initially cannulated via the radial artery using a 5F Simmons 1 diagnostic catheter which was then advanced to the external CA (ECA) over an extra support 0.014" coronary guidewire. After removing the coronary guidewire, a 0.035" guidewire was advanced into the ECA, and the Simmons 1 was exchanged for a 5F or 6F shuttle sheath and positioned in the distal CCA. In four patients with a bovine aortic arch, the left CCA was accessed with a 5F Amplatz R2 catheter which was then exchanged for a shuttle sheath over a 0.035" guidewire. CAS was performed using standard techniques with weight-based bivalirudin for anticoagulation. RESULTS: CAS was successful in 35/42 (83%) patients, including 28/29 (97%) right CA, 4/5 (80%) bovine left CA, 7/13 (54%) left CA. Mean interventional time was 30 +/- 3 minutes. The sheath was removed immediately after the procedure. There were no radial access site complications. One patient sustained a stroke 24 hrs after the procedure with complete resolution of symptoms (Mean NIH stroke scale 2.0 +/- 0.3 before, 1.9 +/- 0.3 after). Median hospital stay was 2 +/- 0.6 days. Inadequate catheter support at the origin of the CCA was the technical cause of failure in the seven unsuccessful cases. CONCLUSION: CAS using the transradial approach appears to be safe and technically feasible. The technique may be particularly useful in patients with right ICA lesions and severe PVD or unfavorable arch anatomy, and among patients with a bovine aortic arch.

Aged↗

PubMed2006

Superficial ulnar artery: curse or blessing in harvesting fasciocutaneous forearm flaps.

BACKGROUND: Superficial ulnar artery is a well-known vascular anomaly that may cause special risks because of possible impairment of the vessel by mistake during harvesting fasciocutaneous forearm flaps. METHODS: The charts of patients who had undergone forearm flap transfer were reviewed for vascular anomalies. When a superficial ulnar artery was present, a superficial ulnar artery flap was raised and arteriography was performed postoperatively to figure out the vascular pattern in the contralateral arm. RESULTS: Four superficial ulnar arteries were found during dissection of ulnar forearm flaps (n = 107). We were unable to identify any superficial ulnar artery when preparing the radial pendant (n = 27), and we did not notice any impairment of such an artery. The four superficial ulnar artery flaps healed uneventfully. Postoperative arteriography revealed a bilateral vascular anomaly in one of the four cases. CONCLUSION: The superficial ulnar artery is a calculable anatomic variation as long as its possible presence is considered during flap harvesting. In these cases, the use of the superficial ulnar artery flap was found to be an easy and safe alternative.

Female↗

PubMedDate not supplied

Pitfalls in posterior fossa myelography.

Positive-contrast myelography of the structures of the posterior fossa is an established and useful technique of examination. The problems peculiar to this method of examination include premyelographic evaluation, identifying pre-existing posttraumatic change and extreme anatomic variations, handling the anxieties of the patient, transporting the opaque bolus from the site of introduction to the area of interest, adequate film documentation of the normal or pathologic state, and postmyelogram headache. A discussion of ways to anticipate and eliminate or minimize the problems is presented.

Cranial Fossa, Posterior↗

PubMedDate not supplied

Melanoma of the head and neck in Queensland.

The incidence of melanoma in Queensland, 40 cases per 100,000 population, is the highest in the world. In this series of 740 melanomas over a 7-year period at the Royal Brisbane Hospital, 21.75% occurred on the head and neck. Of these, 46.5% arose in Hutchinson's melanotic freckle and 54.8% were histologically superficial, that is, Clark Levels I and II or less than 0.76 mm in thickness, or both. As local recurrence and distant metastasis is infrequent in superficial melanoma, less radical surgical excision of these lesions is advocated than for thicker lesions or those exhibiting a greater depth of invasion, where aggressive excision and even regional node dissection may be required. Anatomical variations in areas such as the nose, eyelid, ear, and scalp influence patterns of spread and necessitate differences in treatment at each site.

Adolescent↗

PubMed1988

The tensile strength of natural and chemically modified bovine pericardium.

Nondestructive and destructive uniaxial load tests were performed on natural and chemically modified bovine pericardium. Five specimens were selected from the same sites in different pericardial sacs by using a template. The mean maximum extension of one particular site in both the natural and chemically modified material was significantly greater than that of the other positions at a stress level of 0.6 Nmm.-2 The maximum extensibility of the fixed tissue was significantly greater (p less than 0.01) than that of the natural tissue. There was also an anatomical variation in tensile strength of the natural material which was retained after chemical modification. However, the overall tensile strength of the pericardium was not increased by this procedure. In contrast, glutaraldehyde fixation did increase the percentage strain at which fracture of this biomaterial occurred.

Aldehydes↗

PubMed1990

Transcranial Doppler ultrasonography versus arteriography for assessment of the vertebrobasilar circulation.

The investigation of the vertebrobasilar arterial system by transcranial Doppler (TCD) ultrasonography is difficult due to the numerous anatomical variations in the posterior circulation. To test the validity of TCD, we compared topographic measurements from vertebrobasilar angiograms and corresponding TCD findings in 58 patients with cerebrovascular diseases (N = 37, 21 affecting the vertebrobasilar system), brain tumors (N = 8), and other neurological diseases (N = 13). Normal TCD recordings of the vertebrobasilar system were confirmed by the angiograms in 25 patients, although the noninvasive method failed to separate morphologic variants (N = 15). In patients with pathological conditions of the vertebrobasilar system revealed by either method (N = 17), the combined use of both hemodynamic and radiomorphologic methods improved the diagnostic validity in 24%. We conclude that TCD examination of the posterior fossa circulation provides unambiguous results only if used in combination with cerebral arteriography.

Adult↗

PubMed2003

Atherosclerotic disease distribution in carotid and vertebrobasilar arteries: clinical experience in 100 patients undergoing fluoro-triggered 3D Gd-MRA.

PURPOSE: To determine how often three-dimensional gadolinium-enhanced magnetic resonance angiography (3D Gd-MRA) shows disease outside of the standard two-dimensional time-of-flight magnetic resonance angiography (2D TOF-MRA) imaging volume. MATERIALS AND METHODS: One hundred consecutive patients with known or suspected cerebrovascular disease were examined using fluoro-triggered 3D Gd-MRA with a 1.5 Tesla scanner. All vessel segments from the aortic arch to the circle of Willis were independently evaluated for the presence of occlusive disease, ulceration, aneurysm, and anatomic variations by two radiologists blinded to clinical information. Branch vessel and circle of Willis visibility were also assessed. Kappa statistics were calculated to determine interobserver agreement. RESULTS: Interobserver agreement for the degree of stenosis was good to excellent (kappa = 0.83-1.0). Disagreement was more frequent in the cases of mild stenoses and was less frequent for stenoses > or = 50%. In 38% of the patients, 3D Gd-MRA demonstrated either ulcerated plaques in carotid arteries (N = 14) or stenosis > or = 50% in great vessel (N = 20) and/or vertebral artery (N = 38) origins, none of which can be readily evaluated on standard TOF-MRA. CONCLUSION: Fluoro-triggered 3D Gd-MRA provides a comprehensive evaluation of the carotid arteries including all vessel segments from the aortic arch to the circle of Willis.

Adult↗

PubMedDate not supplied

Appearance of the normal pericardium on coronary MR angiograms.

We evaluated the appearance of the normal pericardium on breath-hold MR images used to visualize coronary arteries. A coronary MR angiogram was obtained in 23 subjects (17 healthy volunteers and six patients with no known pericardial disease) using a breath-hold K-space segmented gradient-recalled echo sequence with fat suppression. Each coronary MR angiographic study included imaging planes equivalent to the following echocardiographic planes: four-chamber view, vertical two-chamber view, and two short-axis views (at base and mid ventricular level). The average pericardial thickness was 1.7 mm (range, 1.5-2.0 mm), and an average length of 60 mm (range, 20-110 mm) of pericardium was visualized. A significantly longer portion of the pericardium was seen in the vertical two-chamber view and the basal short-axis view than in the two other views (P < .001). Normal anatomic variations and overlapping structures and image artifacts can alter the appearance of the pericardium. Breath-hold MR imaging techniques used for coronary MR angiography allow routine, time-efficient evaluation of large portions of the pericardium.

Adolescent↗

PubMed2005

Anthropometric data for magnetic resonance imaging of the carotid bifurcation.

PURPOSE: To provide anthropometric data applicable to the design of protocols for high-resolution magnetic resonance imaging (MRI) of the carotid bifurcation, particularly those aimed at elucidating the role of local factors in carotid atherogenesis. MATERIALS AND METHODS: Axial black-blood MR images of the carotid bifurcation were acquired from 25 young, healthy volunteers and 25 older, asymptomatic patients, from which were measured a variety of quantities related to the orientation and placement of the bifurcation within the neck. RESULTS: Descriptive statistics were obtained for the following quantities: separation of the bifurcation apices within (57.8+/-6.7 mm) and between (4.9+/-4.1 mm) axial slices; orientation of the bifurcation within the axial plane (31.7+/-26.9 degrees ), and of the common carotid artery (CCA) relative to the sagittal (7.5+/-7.1 degrees ) and coronal (7.9+/-7.8 degrees ) planes; depth of the bifurcation from the skin surface (29.5+/-7.2 mm); and neck width (125.9+/-14.4 mm). CONCLUSION: In most cases, both carotid arteries may be captured, without aliasing, within a 12-cm field-of-view axial image; however, the two apices will rarely be captured within the same axial slice. The CCA is significantly oblique to the body axis, but at angles sufficiently acute to permit the use of axial slices. Finally, a significant linear relationship between neck width and carotid depth may be used to inform radio frequency (RF) coil selection prior to scanning a subject, and hence facilitate optimal imaging in light of the wide anatomic variations observed.

Adult↗

PubMed1980

"How I do it"--head and neck. A targeted problem and its solution. Chylous fistula prevention and management.

Prevention of chylous fistulae involves a careful search at the time of surgery for any possible chyle leaks. These should be ligated and the surgeon should be aware of the possible anatomical variations of both the thoracic duct and right lymphatic duct when he is searching for the leak. Treatment of the postoperative chyle fistula consists of elimination of long chain triglycerides from the diet and use of a medium chain triglyceride diet (Portagen), or oral feedings may be discontinued and intravenous fluids used exclusively. The supraclavicular area is treated with aspiration and pressure dressing. If the above measures are unsuccessful then surgical re-exploration is necessary.

Chyle↗

PubMed2004

Hepatectomy of living donors with a left-sided gallbladder and multiple combined anomalies for adult-to-adult living donor liver transplantation.

The left-sided gallbladder is very rare, but it is often accompanied by multiple anomalies of the liver, by which living donor hepatectomy cannot be feasible or becomes difficult. We have experienced 3 donors with a left-sided gallbladder out of 642 living donors. The first case was a male donor showing bifurcating portal anomaly with intrahepatic right portal vein confluence and extremely low bifurcation of the bile ducts. The right lobe was retrieved and implanted to his father. The second case was a male donor revealing trifurcating portal anomaly with separate right posterior portal branch and replacing right posterior hepatic artery. The right posterior segment graft was retrieved and implanted to his uncle. The third case was a male volunteer in whom the anterior portion of the medial segment was fed by an aberrant branch of the right anterior segment glisson. The small left lobe was retrieved and implanted simultaneously with another living donor's left lobe graft in the form of a dual living donor liver transplantation. There was no donor morbidity or recipient complication. Although there is a high possibility of diverse liver anomalies in living donors with a left-sided gallbladder, complete preoperative evaluation and mapping of the multiple anatomical variations may make certain types of living donor hepatectomy feasible.

Abnormalities, Multiple↗

PubMed2003

Complex oncologic reconstruction of a mandibular and floor of mouth defect with a fibula free flap in an achondroplastic patient.

The fibular free flap is seen as one of the foremost technical options in mandibular reconstruction, especially in those defects where long bone is required. Cases with squamous-cell carcinoma of the floor of the mouth with mandibular spread and subsequent segmentary mandibular removal are the cornerstone examples. A case of squamous-cell carcinoma of the whole floor of the mouth with mandibular invasion is reported. Radical resection of the floor of the mouth and bilateral mandibular horizontal ramus was performed, with a bony defect extending from angle to angle. The patient revealed an achondroplastic condition, with remarkable dwarfism and long-bone morphological alterations, that minimized the potential fibular length to transfer. A microsurgical reconstruction with an osteocutaneous fibular free flap was undertaken. The flap design was technically compromised by the forward bowing of the fibula and the ossification of the interosseous membrane. Specific intraoperative strategies for dealing with anatomic variations are discussed. The fibular free flap is an excellent technique for mandibular reconstruction. Morphological deviations can modify the design of the flap. Achondroplasia is not a deterrent in successful use of the free fibula flap for reconstruction of the head and neck in adequately selected cases.

Achondroplasia↗

PubMed1991

Toe transfer for congenital hand defects.

Toe-to-hand transfer is a well-established reconstructive option for certain congenital hand anomalies. It is the only technique which can add growth potential to the immature skeleton. Toe transfer is best suited for constriction ring amputations, which have relatively normal proximal anatomy. Transfers should be performed early in life to avoid lack of cortical integration of the new part. Anatomic variations of both hand and foot are often encountered, which influence both operative approach and functional prognosis. Indications, techniques, and complications are reviewed.

Fingers↗