Outcome after surgical treatment of venous malformations of the hand in childhood

OBJECTIVE

Surgical treatment of venous malformations (VMs) of the hand is challenging. The hand's small functional units, dense innervation, and terminal vasculature can be easily compromised during invasive interventions like surgery or sclerotherapy, leading to an increased risk of functional impairment, cosmetic consequences, and negative psychological effects.

METHODS

We have conducted a retrospective review of all surgically treated patients diagnosed with VMs of the hand between 2000 and 2019 and evaluated their symptoms, diagnostic investigations, complications, and recurrences.

RESULTS

Twenty-nine patients (females, n = 15) with a median age of 9.9 years (range, 0.6-18 years) were included. Eleven patients presented with VMs involving at least one of the fingers. In 16 patients, the palm and/or dorsum of the hand was affected. Two children presented with multifocal lesions. All patients presented with swelling. Preoperative imaging was done in 26 patients and consisted of magnetic resonance imaging in nine patients, ultrasound in eight patients, and both modalities in nine patients. Three patients underwent surgical resection of the lesions without any imaging. Indications for surgery were pain and restriction of function (n = 16), and when lesions were preoperatively evaluated as completely resectable (n = 11). In 17 patients, a complete surgical resection of the VMs was performed, whereas in 12 children, an incomplete resection of VM was deemed due to nerve sheath infiltration. At a median follow-up of 135 months (interquartile range, 136.5 months; range, 36-253 months), recurrence occurred in 11 patients (37.9%) after a median time of 22 months (range, 2-36 months). Eight patients (27.6%) were reoperated because of pain, whereas three patients were treated conservatively. The rate of recurrences did not significantly differ between patients presenting with (n = 7 of 12) or without (n = 4 of 17) local nerve infiltration (P = .119). All surgically treated patients who were diagnosed without preoperative imaging developed a relapse.

CONCLUSIONS

VMs in the region of the hand are difficult to treat, and surgery is associated with a high recurrence rate. Accurate diagnostic imaging and meticulous surgery may contribute to improve the outcome of the patients.

Acute venous problems: Integrating medical, surgical, and interventional treatments

"Acute venous problems" refers to a group of disorders that affect the veins and result in sudden and severe symptoms. They can be classified based on the pathological triggering mechanisms, such as thrombosis and/or mechanical compression, and their consequences, including symptoms, signs, and complications. The management and therapeutic approach depend on the severity of the disease, the location, and the involvement of the vein segment. Although summarizing these conditions can be challenging, the objective of this narrative review was to provide an overview of the most common acute venous problems. This will include an exhaustive yet concise and practical description of each condition. The multidisciplinary approach remains one of the major advantages in dealing with these conditions, maximizing the results and the prevention of complications.

Circumferential Radical Debridement and Omental Free Flap in the Treatment of Severe Chronic Venous Ulcers

BACKGROUND

Chronic venous leg ulcers are a significant health care burden with a difficult and unreliable treatment. Free flaps may be needed for wound coverage in severe cases. Incomplete removal of dermatoliposclerosis (DLS) area and/or not addressing the underlying venous dysfunction may contribute to the reported modest long-term results.

METHODS

A series of 5 patients with severe chronic venous ulcers of the leg, resistant to conservative treatment and superficial venous surgery, were treated with radical, circumferential, subfascial resection of the DLS skin and coverage with omental free flaps. Delayed arteriovenous (AV) loops were used as recipients. All patients had previous superficial venous surgery and multiple skin grafts. Mean follow-up was 8 years (4-15 years).

RESULTS

One hundred percent of flaps survived completely. No major complications occurred. One patient developed ulceration of the flap at 2 years and healed with basic wound care. At a mean follow-up of 8 years, all patients were ulcer-free. One patient died 15 years after the surgery for unrelated causes.

CONCLUSIONS

Radical circumferential resection of DLS area in severe chronic venous leg ulcers and coverage with a free omental flap using staged AV loop provided durable coverage in a series of 5 patients. Complete resection of DLS area, addressing the underlying venous pathology, and draining the flap to a healthy competent vein graft (AV loop) may contribute to these favorable results.

Patency Rates and Outcomes of Renal Access Arteriovenous Fistulas for Hemodialysis in Patients with Chronic Kidney Disease

Hemodialysis remains the most popular modality of renal replacement therapy for end-stage renal disease patients with chronic kidney disease. Various factors such as a radial artery, cephalic vein diameter, age, hypertension, and diabetes mellitus can affect the fistula maturation. This study was carried out to know the patency rates and factors affecting fistula maturation in the Indian population. This is a prospective observational study which aimed to study the patency rate of arteriovenous (AV) fistulas. On the day of surgery, patients were shifted inside the operation theater. Under all aseptic precautions, an AV fistula was formed using the radial artery and cephalic vein. All patients were followed up for 6 months. The data were analyzed using IBM SPSS version 22. To see the change over a period of time, McNemar test for categorical data and repeated measure for continuous data followed by post hoc comparison by Bonferroni method were used. The mean age of the patients was 46.98 ± 13.33 years. The mean diameter of the cephalic vein, ulnar artery, and radial artery at the wrist was 1.733 ± 0.528, 1.700 ± 0.364, and 1.908 ± 0.420, respectively, whereas the mean diameter of the cephalic vein, ulnar artery, and radial artery at the forearm was 1.952 ± 0.488, 1.910 ± 0.421, and 2.058 ± 0.458, respectively. Immediate thrill after the surgery was present in 36/52 (69.2%) of the patients. The radial artery diameter at the wrist was significantly less in the patients with primary failure in whom immediate thrill was not present (P = 0.016). At 1-month follow-up, 30/49 (61.2%) and, at 6 months, 29/48 (60.4%) fistulas were functional. Radiocephalic AV fistulas have a reasonable success rate and minimal morbidity, and radial artery diameter is a good predictor of the outcome.

Resectable fusiform internal jugular vein aneurysm with vascular excision and bypass with an 8 mm Maquet graft: A case report

RATIONALE

Venous aneurysm is a rare vascular disease. Studies reveal that patients with fusiform internal jugular vein aneurysms are not suitable for embolization.

PATIENT CONCERNS

Two treatment options are considered, either bypass the aneurysm via stenting or excision of the lesion site and anastomosis using an artificial graft. The advantages of excision bypass include the absence of endoleak and stent migration; however, a larger wound and longer operation time are required for it.

DIAGNOSES

Physical examination revealed a swelling in the right neck area. Head and neck computed tomography was performed for the survey. It revealed a 27.22 × 25.07 × 58.17 mm internal jugular fusiform aneurysm.

INTERVENTIONS

Vein excision was performed while using hemoclamps to control inflow and outflow, and a graft was anastomosed for bypass using an 8 mm Maquet graft.

OUTCOMES

The wound recovery was favorable, with no signs of infection, and the pain was under control.

LESSONS

The patient had a contrast-enhanced head and neck computed tomography, and the images efficiently diagnosed a venous aneurysm. This patient had refractory pain, which was a significant indication of the operation. We decided by ourselves on the duration of the interval of following up. We used excision and bypassing with graft, and the result was beneficial.

[Efficiency and safety of microsurgical cluster ligation of the spermatic vein]

OBJECTIVE

To study the effect and safety of microscopic varicocele cluster ligation (MVCL).

METHODS

We selected 28 patients undergoing bilateral microscopic spermatic vein ligation in Xuzhou Central Hospital from July 2021 to June 2022. Using the computerized randomization method, we performed MVCL or microscopic varicocele ligation (MVL) for the right or the left spermatic cord, respectively. We recorded the operation time, intraoperative blood loss, the numbers of the spermatic veins ligated and the arteries and lymphatic vessels preserved in each surgical side. A surgeon unaware of the surgical approach on the operative side collected the Visual Analogue Scale (VAS) pain scores, nodular foreign body sensation, relief of scrotal cramps, complications, and long-term recurrence from the patients.

RESULTS

Compared with the MVL group, the MVCL group showed significantly shorter time for spermatic vein ligation (［56.21±13.96］ vs ［31.43±10.13］ min, P<0.01), lower VAS scores on the 1st postoperative day (P <0.05) and a lower incidence of intra-scrotal nodular foreign body sensation in the 1st postoperative month (P <0.05). There were no statistically significant differences in the intraoperative blood loss, numbers of spermatic veins ligated and arteries and lymphatic vessels preserved, VAS scores at 3 and 7 postoperative days, incidence of complications and long-term recurrence between the two groups (P >0.05).

CONCLUSION

MVCL is superior to MVL in reducing the time of spermatic vein ligation and improving the efficiency, efficacy and safety of the procedure, and therefore worthy of clinical promotion.

Transcatheter Arterialization of Deep Veins in Chronic Limb-Threatening Ischemia

BACKGROUND

Approximately 20% of patients with chronic limb-threatening ischemia have no revascularization options, leading to above-ankle amputation. Transcatheter arterialization of the deep veins is a percutaneous approach that creates an artery-to-vein connection for delivery of oxygenated blood by means of the venous system to the ischemic foot to prevent amputation.

METHODS

We conducted a prospective, single-group, multicenter study to evaluate the effect of transcatheter arterialization of the deep veins in patients with nonhealing ulcers and no surgical or endovascular revascularization treatment options. The composite primary end point was amputation-free survival (defined as freedom from above-ankle amputation or death from any cause) at 6 months, as compared with a performance goal of 54%. Secondary end points included limb salvage, wound healing, and technical success of the procedure.

RESULTS

We enrolled 105 patients who had chronic limb-threatening ischemia and were of a median age of 70 years (interquartile range, 38 to 89). Of the patients enrolled, 33 (31.4%) were women and 45 (42.8%) were Black, Hispanic, or Latino. Transcatheter arterialization of the deep veins was performed successfully in 104 patients (99.0%). At 6 months, 66.1% of the patients had amputation-free survival. According to Bayesian analysis, the posterior probability that amputation-free survival at 6 months exceeded a performance goal of 54% was 0.993, which exceeded the prespecified threshold of 0.977. Limb salvage (avoidance of above-ankle amputation) was attained in 67 patients (76.0% by Kaplan-Meier analysis). Wounds were completely healed in 16 of 63 patients (25%) and were in the process of healing in 32 of 63 patients (51%). No unanticipated device-related adverse events were reported.

CONCLUSIONS

We found that transcatheter arterialization of the deep veins was safe and could be performed successfully in patients with chronic limb-threatening ischemia and no conventional surgical or endovascular revascularization treatment options. (Funded by LimFlow; PROMISE II study ClinicalTrials.gov number, NCT03970538.).

Effect of preoperative functional exercise on cephalic vein diameter, anastomotic blood flow, and postoperative complications in patients with arteriovenous internal fistuloplasty

The purpose of this study was to investigate the effect of preoperative functional exercise on cephalic vein diameter, anastomotic blood flow, and postoperative complications in patients with arteriovenous internal fistuloplasty. A total of 140 patients who underwent arteriovenous fistuloplasty from March 2019 to October 2021 were randomly divided into two groups: intervention group (n=70) and control group (n=70). The control group was treated with routine nursing intervention, while the intervention group was treated with preoperative functional exercise and routine nursing intervention. There was no significant difference in the diameter of cephalic vein between the two groups two weeks before the operation (p=0.742). The diameter of cephalic vein in the intervention group was larger than that in the control group two weeks after the operation (p < 0.001), and the blood flow of anastomotic vein in the intervention group was higher than that in the control group two weeks after the operation (p < 0.001). There was no significant difference in the total prevalence of postoperative complications such as vascular stenosis, thrombosis, and swelling hand syndrome between the intervention group and the control group (P=0.546). The findings show that preoperative functional exercise may increase the diameter and blood flow in the vessels, and improve vascular conditions in patients with arteriovenous fistuloplasty, but may have no effect on postoperative complications.

Treatment of arteriovenous fistula with aneurysm using the forearm branch of the cephalic vein as a candidate vessel: A case report

BACKGROUND

Arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis patients due to its better patency rates and fewer complications than other access types. However, some complications related to AVF could not be ignored, including swollen hands and an aneurysm. Although a patient could not continue hemodialysis, it might threaten the patient's life if the rupture of the aneurysm is not immediately treated by the surgeon. A report of using the cephalic vein branch to treat this complication is uncommon.

CASE PRESENTATION

Herein, we present a case of a 42-year-old man in whom an AVF with an aneurysm was successfully treated using the excess cephalic vein branch. This method is a simple and effective intervention for managing aneurysm-associated complications. Additionally, this approach helps maintain the benefits of autogenous access while conserving future dialysis sites.

CONCLUSION

The surgery was effective and safe for this kind of complication with swollen hands and aneurysm. Using the excess cephalic vein branch could reconstruct the AVF.

Internal mammary vein diameter - Is the left side really smaller? A study of 105 bilateral free flap breast reconstruction patients

INTRODUCTION

Autologous free flap breast reconstruction is currently considered as the gold standard in breast reconstruction as it provides a durable, natural result. The internal mammary vessels are the most commonly used recipient vessels in free flap breast reconstruction, and anecdotally we have often observed that the left internal mammary vein (IMV) appears smaller than the right IMV. The aim of this study is to compare the diameters of the right and left IMVs by recording the size of the venous coupler used on each side in a large series of bilateral free flap breast reconstructions.

METHODS

We searched our free flap database for patients who had breast reconstruction between October 2018 and August 2021. Inclusion criteria for this study were bilateral breast reconstruction patients, where the internal mammary vessels were used. We used a paired t-test for statistical analysis of the data.

RESULTS

A total of 105 patients who had bilateral breast reconstruction were included in this study. Their mean age was 48.4 years. The mean venous coupler size used on the right was 2.64 mm (SD 0.35), whilst the mean left IMV coupler size was 2.48 (SD 0.32). Using a paired t-test, the p value for the comparison of the right and left IMV size in the cohort was 0.00032, demonstrating a statistically significant difference.

CONCLUSION

We have confirmed that the right IMV is larger in diameter than the left side, and demonstrated that this translates into a recordable practical difference in the coupler size used. Despite this, we experienced no venous congestion or flap failures in our left-sided flaps, indicating that the IMVs remain a safe choice of recipient vein.

Development of chronic venous disease

INTRODUCTION

Chronic venous disease is known to gradually worsen in the course of years. However, little clinical data is available. The patient group and methods: We used the set of our patients with completed clinical examination, duplex sonography and photoplethysmography and selected 160 patients examined at our office after 10 and more years. Females represented 79% in the group. The mean age was 54 years (range 18-82 years). Venous varices in lower limbs in the family were reported by 49% patients. Venous sclerotization had been undergone by 6.3% and venous surgery by 10.6% patients. The mean body mass index was 27. We used CEAP classification. The clinical class C1 included 50 patients, C2 included 81, C3 included 15 and C4 included 14 patients. Regurgitation in superficial veins was found in 43%. The mean venous return time after physical activity was 24.5 s.

RESULTS

The last examination was performed after 13 years on average (range 10-28 years). Deterioration of the clinical condition and progression to a higher class were observed in 36% patients in class C1, in 23.5% patients in C2, in 13% patients in C3 and in 7% patients in C4. We did not demonstrate any statistically significant effect of the followed parameters on the progression of the disease.

CONCLUSION

The progression rate of the disease in our patient group followed at the vascular office for 10 and more years is lower compared to population studies.

Retrograde Free Venous Flaps for Extremity Reconstruction: A Roadmap

Background and Objectives: Retrograde free venous flaps represent a separate entity among free venous flaps: their physiology is still unclear, but they provide an immediate visible refill after reconnection, with a similar behaviour to conventional flaps. Therefore, the dimensions and the indications of these flaps can be extended beyond what was previously believed, and they can be easily customized, including with respect to tendons and nerves. Nevertheless, they are still debated and regarded as unsafe. Materials and Methods: From 2012 to 2019, we performed 31 retrograde free venous flaps on 31 patients to reconstruct hands, digits, and in one case the heel. All the flaps were arterialized in a retrograde manner; the donor site was the forearm in 28 cases, the foot in 2 cases, and the calf in 1 case. We recorded the size, vein architecture, donor site, donor artery, donor morbidity, function for composite and non-composite flaps, immediate complications, late complications, survival rate, and the number of revisions. We recorded the hand function when appropriate. A total of 10 flaps were also intraoperatively studied with indocyanine green to monitor their hemodynamical behaviour. Results: All the patients were followed for an average of 8 months (6−15). The flap dimensions ranged from 6 cm2 to 136 cm2. All the flaps, except two that had complete necrosis, survived. Two flaps had partial necrosis. There was no correlation between necrosis and the size of the flap, with one case of necrosis and one of partial necrosis in the small flaps (<10 cm2). None of the cases with partial necrosis needed a new flap. Two flaps developed a late arterio-venous shunt that was ligated. Conclusions: The retrograde free venous flaps proved to be a useful tool for complex reconstructions of the hand and extremities. They can provide a large island of pliable skin and composite tissue with tendons and nerves, but surgeons must be aware of some caveats.

Selection of Optimal Functional Lymphatic Vessel Cutoff Size in Supermicrosurgical Lymphaticovenous Anastomosis in Lower Extremity Lymphedema

BACKGROUND

Functional lymphatic vessels are essential for supermicrosurgical lymphaticovenous anastomosis. Theoretically, the larger the lymphatic vessel, the better the flow. However, large lymphatic vessels are not readily available. Since the introduction of lymphaticovenous anastomosis, no guidelines have been set as to how small a lymphatic vessel is still worthwhile for anastomosis.

METHODS

In this longitudinal cohort study, unilateral lower limb lymphedema patients who underwent lymphaticovenous anastomosis between March of 2016 and January of 2019 were included. Demographic data and intraoperative findings including the number and size of lymphatic vessels were recorded. The cutoff size was determined by receiver operating characteristic curve analysis, based on the functional properties of lymphatic vessels. Clinical correlation was made with post-lymphaticovenous anastomosis volume measured by magnetic resonance volumetry.

RESULTS

A total of 141 consecutive patients (124 women and 17 men) with a median age of 60.0 years (range, 56.7 to 61.2 years) were included. The cutoff size for a functional lymphatic vessel was determined to be 0.50 mm (i.e., lymphatic vessel0.5) from a total of 1048 lymphatic vessels. Significant differences were found between the number of lymphatic vessels0.5 anastomosed (zero to one, two to three, and greater than over equal to four lymphatic vessels0.5), the median post-lymphaticovenous anastomosis volume reduction (in milliliters) (p < 0.001), and the median percentage volume reduction (p = 0.012).

CONCLUSIONS

Lymphatic vessel0.5 can be a valuable reference for lymphaticovenous anastomosis. Post-lymphaticovenous anastomosis outcome can be enhanced with the use of lymphatic vessel0.5 for anastomoses.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

An Analysis of Major Causes of Surgical Failure Using Bähren System in Intraoperative Venography During Varicocelectomy

PURPOSE

In young patients with varicocele, preservation of the internal spermatic artery may be advantageous for catch-up growth, but it may also increase the likelihood of treatment failure. Intraoperative venography reduces the likelihood that unsealed veins will remain after varicocelectomy. We analyzed the characteristics of remnant veins visualized through intraoperative venography to investigate the cause of surgical failure in artery-sparing varicocelectomy (ASV).

MATERIALS AND METHODS

We retrospectively analyzed clinical characteristics and outcomes of patients aged 18 years or younger who underwent varicocelectomy with intraoperative venography from January 2005 to December 2017. During varicocelectomy, intraoperative venography was performed to distinguish veins from other structures. Any unsealed veins that were discovered were ligated and classified using the Bahren system.

RESULTS

One hundred and sixty-two patients underwent intraoperative venography: 153 cases (94.4%) were for primary varicocelectomy, and 9 cases (5.6%) were for repeat varicocelectomy. Open varicocelectomy was performed in 105 cases (64.8%), and laparoscopic varicocelectomy was performed in 57 cases (35.2%). Venography revealed remnant veins after the first ligation in 51 cases (31.2%), 46 (90.2%) and 5 (9.8%) of which were Bähren types 3 and 4, respectively. Five patients (3.1%) experienced varicocele recurrence, classified as persistence in 1 patient (0.6%) and relapse in 4 patients (2.5%).

CONCLUSION

Remnant collateral veins of the internal spermatic vein (ISV) (Bahren type 3) are the most common cause of failure in ASV. In a few patients, an external spermatic vein merges with the ISV at a higher level (Bahren type 4) and is unidentifiable without venography.

The impact of a double vein anastomoses on doppler's loss of signal rates

BACKGROUND

Impact on blood flow by double vein anastomosis in head and neck free flaps is unclear. We aimed to assess venous doppler loss of signal (LOS) rates of double vein system compared with a single vein system.

METHODS

Consecutive free flaps with implanted venous flow couplers between 2015-2017 were included. LOS rates were compared between groups and with regard to flap type, defect site and recipient vein within double vein group.

RESULTS

92 double-vein (184 veins) and 48 single-vein flaps were included. LOS was similar in single- and double-vein flaps (11/48 (25%) versus 46/184 (25%), p = 0.765). Double veins had fewer flap takebacks compared with single vein (4.3% vs. 12.5%, p = 0.075). Common facial vein (CFV) anastomosis showed superior LOS rates compared with external jugular and CFV branches (p = 0.026).

CONCLUSIONS

Double vein anastomosis does not impact LOS rates, results in fewer flap takebacks, yet LOS rates depend on selected recipient vein.

Anterolateral thigh free flaps with T-shaped pedicles and multiple venous anastomosis for extremity reconstruction

The anterolateral thigh free flap is one of the most preferred options for reconstructing soft tissues of the extremities and vascular anastomosis is one of the most important factors for flaps survival. T-anastomosis and double venous anastomosis have been widely used for increasing flap survival. This report shows both application of T-shape pedicle and multiple venous anastomosis to each 43 cases for extremity reconstruction that have not been described so far in the literature and it showed the necessity of multiple anastomosis. The locations of the lesions were 8 upper extremities (4 hands, 3 forearms, and 1 upper arm) and 35 lower extremities (5 forefeet, 6 dorsal feet, 4 plantar feet, 11 ankles, and 9 lower legs). We applied T-shaped arterial pedicle to limited anatomical area that had 2 or more major arterial communication sites to overcome the obstruction by reverse flow from communication vessels when 1 of the 2 anastomosis was obstructed. We classified multiple venous anastomosis according to flow direction and the vascular connections between the superficial and deep veins. In result, 37 cases survived completely but 2 flaps developed severe necrosis (>50%) because of infection and hematoma and 4 flaps developed partial necrosis due to wound infection. In conclusion, T-shaped pedicle and multiple venous anastomosis is a method to improve free flap survival and useful in cases where sacrificing a dominant vessel is inevitable or those in which only 1 vessel remains.

Superficial versus deep system single venous anastomosis in the radial forearm free flap: a meta-analysis

The selection of the superficial or deep drainage system for use with the radial forearm free flap (RFFF) remains controversial. The aim of this study was to identify the optimal drainage system for single venous anastomosis. A systematic review and cumulative meta-analysis was performed to assess superficial and deep system single venous anastomosis for use with the RFFF in postoperative reconstruction of the head and neck. This study included 1073 flaps (495 superficial system-based flaps, 578 deep system-based flaps) reported in six studies. The outcomes assessed in the studies selected for this meta-analysis included venous compromise, flap failure, and the salvage success rate. Venous compromise was more common in the superficial system group (odds ratio (OR) 2.29, 95% confidence interval (CI) 1.36-3.86, P=0.002). The rate of successful salvage was higher with the superficial system (OR 8.19, 95% CI 1.75-38.3, P=0.008). The rate of flap failure was lower in the superficial system group (OR 0.30, 95% CI 0.04-2.48, P=0.27). Although the deep system showed a lower risk of venous compromise, the evidence provided by the meta-analysis was insufficient to determine which type of drainage system is more suitable for single venous anastomosis in RFFF. All included studies were cohort studies; therefore, findings must be interpreted with caution.

Surgical treatment of carpal tunnel syndrome in advanced-stage upper extremity lymphedema: A case report

RATIONALE

Despite significant advances in microsurgical techniques, simultaneous release of transverse carpal ligament (TCL) and lymphovenous anastomosis (LVA) surgeries may be effective for treatment of carpal tunnel syndrome (CTS) and advanced-stage lymphedema. This case report describes the successful treatment of lymphedema with LVA in a patient with CTS and advanced-stage lymphedema.

PATIENT CONCERNS

A 60-year-old female patient was referred to our lymphedema clinic with a 12-year history of chronic, acquired, right upper extremity lymphedema and CTS following right mastectomy and axillary lymph node dissection and adjuvant chemoradiotherapy for treating breast cancer.

DIAGNOSIS

According to the indocyanine green lymphography, magnetic resonance lymphangiography, and electromyography, the patient was diagnosed with CTS and advanced-stage lymphedema (International Society of Lymphology late stage 2).

INTERVENTION

Release of the TCL was performed first, followed by LVA at the wrist, forearm, and antecubital area. The right arm was compressed and elevated immediately postoperatively and postoperative compression bandage therapy with 35 to 40 mm Hg pressure was instituted following surgery.

OUTCOMES

After 2 simultaneous surgeries, the patient had significant circumference and volume reduction of the right hand. The CTS and lymphedema symptoms have decreased following synchronous TCL release and LVA surgeries.

LESSONS

Simultaneous LVA and release of the TCL may be effective and safe in patients with advanced lymphedema and CTS.

Muscle in vein conduits: our experience

Muscle in vein (MIV ) conduits have gradually been employed in the last 20 years as a valuable technique in bridging peripheral nerve gaps after nerve lesions who cannot undergo a direct tension-free coaptation. The advantages of this procedure comparing to the actual benchmark (autograft) is the sparing of the donor site, and the huge availability of both components (i.e. muscle and veins). Here we present a case serie of four MIV performed at our hospital from 2018 to 2019. The results we obtained in our experi-ence confirmed its effectiveness both in nerve regeneration (as sensibility recovery) and in neuropathic pain eradication. Our positive outcomes encourage its use in selected cases of residual nerve gaps up to 30 mm.