A Possible Newly Defined and Treatable Secondary Cause of Early Morning Wake-Up Headaches in an Older Hypermobile Woman: Nutcracker Physiology with Spinal Epidural Venous Congestion

Introduction

Left renal vein compression (nutcracker physiology) with secondary spinal epidural venous congestion is a newly recognized cause of daily persistent headache. Presently, only women with underlying symptomatic hypermobility issues appear to develop headache from this anatomic issue. The hypothesized etiology is an abnormal reset of the patient's cerebrospinal fluid (CSF) pressure to an elevated state. Headaches that occur during sleep can have a varied differential diagnosis, one of which is elevated CSF pressure. We present the case of an older woman who began to develop severe wake-up headaches at midnight. She was found to have left renal vein compression and spinal epidural venous congestion on imaging. After treatment with lumbar vein coil embolization, which alleviated the spinal cord venous congestion, her headaches alleviated.

Case Report

A 61-year-old woman with a history of hypermobile Ehlers-Danlos syndrome began to be awakened with severe head pain at midnight at least several times per week. The headache was a holocranial, pressure sensation, which worsened in the supine position. The headaches were mostly eliminated with acetazolamide. Because of her hypermobility issues and pressure-like headache, she was investigated for underlying nutcracker physiology and spinal epidural venous congestion. This was confirmed using magnetic resonance (MR) angiography and conventional venography, and after lumbar vein coil embolization her wake-up headaches ceased.

Conclusion

The case report suggests a possible new underlying and treatable cause for early morning, wake-up headaches: nutcracker physiology with secondary spinal epidural venous congestion. The case expands on the clinical headache presentation of nutcracker physiology.

A secondary daily persistent headache from onset with underlying nutcracker physiology and spinal epidural venous congestion: case series with lumbar vein embolization as a therapeutic approach

The authors have published on a unique subset of patients whose headaches worsened in the Trendelenburg position and who on time-resolved MR angiography demonstrated left renal vein compression (nutcracker physiology) with retrograde left second lumbar vein (L2LV) flow and regional spinal epidural venous plexus (EVP) congestion. We hypothesized that the spinal EVP congestion subsequently causes a secondary congestion of the cerebral venous system, which then leads to an elevation of CSF pressure above that individuals CSF pressure set point. This results in a daily headache from onset. Thus, eliminating the spinal EVP could conceivably improve or eliminate the manifested headache syndrome. We now present a case series of four patients with long-term follow-up utilizing lumbar vein coil embolization as a new therapeutic approach. In each patient, the MR angiography findings were verified by catheter-based venography. Treatment consisted of endovascular embolization of the second lumbar vein. Four patients have had coil embolization of which three are 1 year or longer from their procedure while one is 10 months posttreatment. All patients were women. Duration of daily headache prior to embolization ranged from 4 to 8 years. Post-embolization: Three patients are either headache free or 90-95% improved with substantial pain free time. There were no procedure-related complications. Our results suggest that embolization of L2LV in a specific patient population with nutcracker physiology may substantially improve head pain issues. This is a minimally invasive outpatient technique with no apparent side effects.

Novel Use of Time-Resolved Magnetic Resonance Angiography to Evaluate Retrograde Lumbar Vein Flow and Epidural Venous Plexus Enhancement in Chronic Headache Patients With and Without Nutcracker Physiology

OBJECTIVE

Compression of the left renal vein by the superior mesenteric artery, known as nutcracker phenomenon (NCP), can cause retrograde flow and congestion in communicating venous systems. It has recently been speculated that NCP can result in retrograde flow and congestion of the lumbar veins and epidural venous plexus (EVP), thereby affecting the central nervous system. This study describes the novel use of time-resolved magnetic resonance angiography (trMRA) to evaluate for retrograde left second lumbar vein (L2LV) flow and early EVP enhancement in patients with chronic daily headache (CDH) with and without NCP.

METHODS

A retrospective analysis was performed of 31 patients with CDH (27 females and 4 males; median age, 38 years [range, 18-63 years]) who underwent trMRA centered over the L2LV to evaluate the direction of blood flow and presence of early EVP enhancement from May 2020 to March 2022. Descriptive statistics were performed, and anatomic associations were analyzed in patients with and without retrograde L2LV flow and early EVP enhancement. The accuracy of magnetic resonance imaging findings in detecting these flow patterns was also assessed.

RESULTS

Patients with NCP who demonstrated narrowing of the left renal vein, a positive beak sign ( P = 0.052), decreased aortomesenteric distance ( P = 0.038), and decreased SMA angle demonstrated increased rates of retrograde L2LV flow and early EVP enhancement. A positive beak sign was 83% specific, and an aortomesenteric distance of ≤6.5 mm was 61% sensitive and 83% specific for identifying retrograde L2LV flow with early regional EVP enhancement in patients with CDH.

CONCLUSIONS

Retrograde L2LV flow with early EVP enhancement in CDH patients can be effectively evaluated using trMRA and was seen with greater propensity in those patients with NCP.

Daily persistent headache with nutcracker physiology and spinal epidural venous congestion: Treatment with lumbar vein embolization

Nutcracker phenomenon (NCP) can cause various congestion syndromes secondary to the superior mesenteric artery (SMA) compressing the left renal vein (LRV) resulting in venous reflux. It has recently been suggested that reflux into the lumbar vein (LV) and epidural venous plexus (EVP) may cause headaches in some patients with NCP. This report illustrates an example of a patient with refractory headaches and imaging findings suggestive of NCP that underwent treatment with percutaneous LV embolization. The patient is a 60-year-old female with daily persistent headaches for 5 years that failed numerous headache preventative medications. Time-resolved magnetic resonance angiography demonstrated NCP with reflux and congestion of the LV and EVP. Catheter-based venography confirmed these findings and the patient was treated with percutaneous embolization of the LV. This case report demonstrates the use of LV embolization to prevent EVP reflux and treat daily headaches due to NCP. The patient's headache resolved the next day. She has been headache-free for 5 months post-treatment. These findings support prior data suggesting that NCP can cause retrograde LV flow, EVP congestion, and elevated cerebrospinal fluid pressures leading to daily persistent headaches. Percutaneous embolization of the LV may be a minimally invasive treatment option for refractory headaches in patients with NCP, retrograde LV flow, and EVP congestion.

Radiation Segmentectomy for the Treatment of Primary Hepatic Malignancies of the Caudate Lobe: A Case Series

PURPOSE

Tumors involving the caudate lobe present a unique therapeutic challenge due to their complex anatomy and the safety and efficacy of locoregional therapy can be variable. The purpose of this study is to analyze the outcomes of radiation segmentectomy for primary caudate lobe tumors.

MATERIALS AND METHODS

Eight patients [5 women and 3 men; median age = 69 y (range 50-79)] that underwent transarterial radioembolization (TARE) using yttrium-90 (Y90) glass microspheres for primary caudate lobe tumors (hepatocellular carcinoma = 6, intrahepatic cholangiocarcinoma = 2) from August 2017 to March 2021 were retrospectively analyzed. Descriptive statistics, treatment parameters, tumor response (using modified response evaluation criteria in solid tumors), adverse events [using common terminology criteria for adverse events (CTCAE)], and survival outcomes were evaluated.

RESULTS

Eight primary caudate lobe tumors with a median size of 2.2 cm [interquartile range (IQR), 1.7-3.3] and Child-Pugh class A liver function underwent TARE of the caudate lobe. The median radiation dose was 596 Gy (IQR 356-1585), median total activity was 0.84 GBq (IQR 0.56-1.31), median specific activity was 473 Bq/sphere (IQR 226-671), and the median number of Y90 microspheres used was 1.4 million (IQR 1.2-3.4). All complications were CTCAE grade 1, and no clinically significant hilar plate complications were observed. In targeted tumors, complete response was seen in all patients.  At a median follow-up period of 16.6 months (IQR 6.6-21.6) 75% (6/8) of patients were alive with no in-field progression.

CONCLUSION

Radiation segmentectomy of primary caudate lobe tumors appears effective and is well tolerated in this limited case series within the described treatment parameters.

LEVEL OF EVIDENCE

Level 4, Case Series.

Radiation Segmentectomy for the Treatment of Solitary Hepatocellular Carcinoma: Can Outcomes Be Compared to Surgical Resection?

PURPOSE

To investigate outcomes of radiation segmentectomy (RS) versus standard-of-care surgical resection (SR) as a quality endeavor.

MATERIALS AND METHODS

A multisite, retrospective, analysis of treatment-naïve patients who received either RS or SR was performed. Inclusion criteria were solitary HCC ≤8 cm, Eastern Cooperative Oncology Cohort performance status 0-1, and absence of macrovascular invasion or extrahepatic disease. Target tumor and overall progression, time-to-progression (TTP), and overall survival were assessed. Outcomes were censored for liver transplantation.

RESULTS

123 patients were included (RS:57, SR:66). Tumor size, Child-Pugh class, ALBI score, platelet count, and fibrosis stage were significantly different between cohorts (p≤0.01). Grade ≥3 adverse events per Clavien-Dindo classification occurred in 0 RS vs 13(20%) SR patients. Target tumor progression occurred in 3(5%) RS and 5(8%) SR patients, and overall progression in 19(33%) RS and 21(32%) SR patients. Median overall TTP was 21.9 and 29.4 months after RS and SR, respectively (95%CI:15.5-28.2 and 95%CI:18.5-40.3, p=0.03). Overall TTP subgroup analyses showed no difference between cohorts with fibrosis stage 3-4 (p=0.26) and platelets <150x10⁹/L (p=0.29). The overall progression hazard ratio for RS vs SR was not significant per multivariate cox regression analysis (1.16, 95%CI:0.51-2.63, p=0.71). Median overall survival was not reached for either cohort. Propensity scores were calculated but were too dissimilar for matching.

CONCLUSION

Radiation segmentectomy and surgical resection are performed in different patient populations, which limits comparison. Radiation segmentectomy approaches surgical resection outcomes, with a lower incidence of major adverse events, in patients who are not eligible for hepatectomy.

Safety and initial efficacy of ablative radioembolization for the treatment of unresectable intrahepatic cholangiocarcinoma

PURPOSE

To investigate safety, response, and survival after ablative glass microsphere ⁹⁰Y radioembolization for unresectable intrahepatic cholangiocarcinoma.

MATERIALS AND METHODS

A retrospective review of 37 radioembolizations in 28 patients treated with single compartment dose of ≥190 Gy encompassing >75% of the largest tumor was performed. Tumors were assessed for stage, morphology, and arterial supply. Response per Modified Response Evaluation Criteria in Solid Tumors (mRECIST), freedom from progression (FFP), progression-free survival (PFS), overall survival (OS), biochemical hepatic function, performance status, and adverse events were investigated.

RESULTS

The median highest dose per patient was 256.8 Gy (195.7-807.8). Objective response at 3 months was 94.1% (complete 44.1% and partial 50%). Median OS was not reached and the 30-month OS rate was 59%, with a median follow-up of 13.4 months (5.4-39.4). FFP in the radiated field and overall FFP at 30 months were 67% and 40%, respectively. Favorable arterial supply was associated with improved OS (p = 0.018). Unfavorable arterial supply was associated with worse OS [HR 5.7 (95% CI 1.1-28.9, p = 0.034)], and PFS [HR 5.9 (95% CI 1.9-18.4, p = 0.002)]. Patients with mass-forming tumors had a survival benefit (p = 0.002). Laboratory values and performance status did not significantly change 3 months after radioembolization. Grade 3 and 4 adverse events occurred in 2 (7.1%) patients.

CONCLUSIONS

Radioembolization of unresectable intrahepatic cholangiocarcinoma with ablative intent has a high response rate, promising survival, and is well tolerated.

Iliocaval reconstruction of chronically thrombosed cylindrical inferior vena cava filters with balloon expandable covered stent-grafts

The use of a Viabahn VBX endoprosthesis (W. L. Gore & Associates, Flagstaff, Ariz) to exclude chronically thrombosed inferior vena cava (IVC) filters refractory to exclusion with self-expanding stents was evaluated. The mean duration of TrapEase IVC (Cordis, Milpitas, Calif) implantation was 7.6 years (range, 2-11 years). Symptoms included leg pain, edema, color changes, and back pain. The mean Villalta score and venous clinical severity score were 17 (range, 13-23) and 13 (range, 11-15), respectively. Indirect ultrasound evidence of stent patency was demonstrated at a mean of 8 months after intervention. The mean Villalta score and venous clinical severity score had decreased by 13 and 10, respectively, at a mean of 9.5 months after intervention. Iliocaval reconstruction with Viabahn VBX balloon expandable stent-graft exclusion of chronically thrombosed TrapEase IVC filters is safe, with favorable short-term results.

Biochemical Safety of Ablative Yttrium-90 Radioembolization for Hepatocellular Carcinoma as a Function of Percent Liver Treated

Purpose

Transarterial radioembolization can serve as an ablative therapy for early-stage hepatocellular carcinoma (HCC). Given the volumetric variability of liver segments, this study aimed to characterize the safety of ablative radioembolization by determining percent liver treated (%LT) thresholds associated with biochemical toxicity.

Patients and Methods

Patients with HCC receiving a single ablative radioembolization treatment using glass microspheres from 2017 through 2020 were reviewed. %LT was calculated as treatment angiosome volume divided by whole liver volume. Biochemical toxicities were defined as increases in Albumin-Bilirubin (ALBI) grade or Child-Pugh (CP) class compared to baseline and albumin or bilirubin adverse events (AEs) per the Common Terminology Criteria for Adverse Events. Receiver operating characteristic curves and multivariate logistic regression analyses were performed to assess the impact of %LT on toxicities.

Results

Of 141 patients analyzed, 53% (n=75) were ALBI 1, 45% (n=64) ALBI 2, 79% (n=111) CP-A, and 21% (n=30) CP-B. A %LT ≥14.5% was associated with grade/class increases in ALBI 2 (p≤0.01) and CP-B patients (p=0.026). In multivariate analysis, a %LT ≥14.5% was an independent predictor of increases in the ALBI 2 and CP-B groups (p<0.01). No significant %LT threshold was found for ALBI 1 and CP-A patients. No grade 3/4 albumin or bilirubin AEs were reported, while grade 2 AEs were related to an initial whole liver volume <1.3 L (p≤0.01).

Conclusion

Patients with ALBI 2 and CP-B liver function are less likely to have an increase in their respective grade/class when treating <14.5% of the liver using glass microspheres. ALBI 1 and CP-A patients showed no definitive %LT threshold for biochemical toxicity within the range of this study.

Natural History of Incidental Enhancing Nodules on Cone-Beam Computed Tomography during Transarterial Therapy of Hepatocellular Carcinoma

PURPOSE

To evaluate the natural history of incidental enhancing nodules (IENs) on contrast-enhanced cone-beam computed tomography (CT) during transarterial treatment of hepatocellular carcinoma (HCC).

MATERIAL AND METHODS

A single-center retrospective analysis of 100 patients with HCC who underwent contrast-enhanced cone-beam CT prior to transarterial treatment from August 2015 to June 2019 was performed. Inclusion criteria were patients with segmental distribution sublobar HCC, contrast-enhanced cone-beam CT of the target lesion and nontarget liver parenchyma, and follow-up cross-sectional imaging. Patients with IENs ≥3 mm that did not meet imaging criteria for HCC were analyzed. Exclusion criteria included biphenotypic tumors and IEN present inside the treated area of the liver.

RESULTS

Fifty-six patients demonstrated 154 IENs on contrast-enhanced cone-beam CT, of which 13 IENs (8.5%) progressed to HCC. The mean primary tumor size was 29 mm (range: 10.2-189 mm). Ten patients had ≥4 IENs, and 46 patients had 1-3 IENs. The mean IEN size was 6.8 mm (range: 3.0-16.3 mm). The median follow-up interval after contrast-enhanced cone-beam CT was 282 days (interquartile range: 143-522). Increased alpha-fetoprotein before treatment (≥15.5 ng/mL, P = .035), having ≥4 IENs (P = .020), and hepatitis C virus (P = .015) were significantly correlated with IEN progression to HCC. No statistically significant differences were identified in baseline neutrophil-to-lymphocyte ratio, targeted HCC characteristics (size, macrovascular invasion, infiltrative pattern, enhancement pattern, and satellite lesions), and IEN size between those with IEN progression to HCC and those without.

CONCLUSIONS

Most IENs of ≥3 mm on contrast-enhanced cone-beam CT in patients with segmental distribution sublobar HCC do not progress to HCC. Patients with segmental distribution sublobar HCC with ≥4 IENs, alpha-fetoprotein elevation (≥15.5 ng/mL), or hepatitis C virus have an increased risk of IEN progression to HCC.

Incidence of acute pulmonary embolism among patients hospitalized with COVID-19: a systematic review and meta-analysis

Background: Coronavirus disease 2019 (COVID-19) is a global pandemic, which is associated with venous thromboembolism and pulmonary embolism (PE). This study aimed to estimate the pooled incidence of PE among patients hospitalized with COVID-19 within the published literature. Methods: This systematic review and meta-analysis was performed according to PRISMA guidelines. An electronic search using MEDLINE /PubMed, ScienceDirect, Cochrane, and OpenGray databases was conducted May 19th, 2020. Eligible studies included sufficient data to calculate the incidence of PE diagnosed during hospitalization in patients with COVID-19. Case reports were excluded. Quality was assessed using the Newcastle-Ottawa scale (observational cohort and case-control), AXIS tool (cross-sectional), and quality assessment tool (case series). Demographics and PE incidence data were extracted from the included studies and analyzed with R language. The pooled incidence of PE in patients hospitalized with COVID-19 was calculated. Results: The database search identified 128 records. Ten observational studies were eligible and were included in the meta-analysis with a total of 1722 patients (mean age= 63.36). .The incidence of PE was noted to be higher in males. The D-dimer levels were specified between PE group and non-PE group in only three studies, while the remaining either reported it improperly or had missing data.The pooled PE incidence in patients hospitalized with COVID-19 was 17% (95% CI: 0.1-0.26). There was a high degree of study heterogeneity (I2 = 94%, p<0.01). Conclusion: The pooled PE incidence in patients hospitalized with COVID-19 is 17%. This increased incidence is greater than that previously reported in the general population of non-COVID-19. Attention and further investigation of this risk is warranted.

Deep vein thrombosis and pulmonary embolism among hospitalized coronavirus disease 2019-positive patients predicted for higher mortality and prolonged intensive care unit and hospital stays in a multisite healthcare system

Objective

We assessed the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) in hospitalized patients with coronavirus disease 2019 (COVID-19) compared with that in a matched cohort with similar cardiovascular risk factors and the effects of DVT and PE on the hospital course.

Methods

We performed a retrospective review of prospectively collected data from COVID-19 patients who had been hospitalized from March 11, 2020 to September 4, 2020. The patients were randomly matched in a 1:1 ratio by age, sex, hospital of admission, smoking history, diabetes mellitus, and coronary artery disease with a cohort of patients without COVID-19. The primary end point was the incidence of DVT/PE and the odds of developing DVT/PE using a conditional logistic regression model. The secondary end point was the hospitalization outcomes for COVID-19 patients with and without DVT/PE, including mortality, intensive care unit (ICU) admission, ICU stay, and length of hospitalization (LOH). Multivariable regression analysis was performed to identify the variables associated with mortality, ICU admission, discharge disposition, ICU duration, and LOH.

Results

A total of 13,310 patients had tested positive for COVID-19, 915 of whom (6.9%) had been hospitalized across our multisite health care system. The mean age of the hospitalized patients was 60.8 ± 17.0 years, and 396 (43.3%) were women. Of the 915 patients, 82 (9.0%) had had a diagnosis of DVT/PE confirmed by ultrasound examination of the extremities and/or computed tomography angiography of the chest. The odds of presenting with DVT/PE in the setting of COVID-19 infection was greater than that without COVID-19 infection (0.6% [5 of 915] vs 9.0% [82 of 915]; odds ratio [OR], 18; 95% confidence interval [CI], 8.0-51.2; P < .001). The vascular risk factors were not different between the COVID-19 patients with and without DVT/PE. Mortality (P = .02), the need for ICU stay (P < .001), duration of ICU stay (P < .001), and LOH (P < .001) were greater in the DVT/PE cohort than in the cohort without DVT/PE. On multivariable logistic regression analysis, the hemoglobin (OR, 0.71; 95% CI, 0.46-0.95; P = .04) and D-dimer (OR, 1.0; 95% CI, 0.33-1.56; P = .03) levels were associated with higher mortality. Higher activated partial thromboplastin times (OR, 1.1; 95% CI, 1.00-1.12; P = .03) and higher interleukin-6 (IL-6) levels (OR, 1.0; 95% CI, 1.01-1.07; P = .05) were associated with a greater risk of ICU admission. IL-6 (OR, 1.0; 95% CI, 1.00-1.02; P = .05) was associated with a greater risk of rehabilitation placement after discharge. On multivariable gamma regression analysis, hemoglobin (coefficient, −3.0; 95% CI, 0.03-0.08; P = .005) was associated with a prolonged ICU stay, and the activated partial thromboplastin time (coefficient, 2.0; 95% CI, 0.003-0.006; P = .05), international normalized ratio (coefficient, −3.2; 95% CI, 0.06-0.19; P = .002) and IL-6 (coefficient, 2.4; 95% CI, 0.0011-0.0027; P = .02) were associated with a prolonged LOH.

Conclusions

A significantly greater incidence of DVT/PE occurred in hospitalized COVID-19–positive patients compared with a non–COVID-19 cohort matched for cardiovascular risk factors. Patients affected by DVT/PE were more likely to experience greater mortality, to require ICU admission, and experience prolonged ICU stays and LOH compared with COVID-19–positive patients without DVT/PE. Advancements in DVT/PE prevention are needed for patients hospitalized for COVID-19 infection.

Pathologic Response of Hepatocellular Carcinoma Treated with Yttrium-90 Glass Microsphere Radiation Segmentectomy Prior to Liver Transplantation: A Validation Study

PURPOSE

To evaluate the pathologic outcomes of hepatocellular carcinoma (HCC) treated with Yttrium-90 radiation segmentectomy using glass microspheres prior to liver transplantation and explore parameters associated with pathologic necrosis.

MATERIALS AND METHODS

A single-institution retrospective analysis of HCC patients who received radiation segmentectomy prior to liver transplantation from November 2016 to May 2020 was performed. Patients were included if the treatment angiosome encompassed the entire tumor and could be correlated with available gross pathology. Archived histology slides were reviewed for percentage of pathologic necrosis. Thirty-three patients with 37 tumors were evaluated. The median tumor size was 2.3 cm (range, 1-6.7 cm).

RESULTS

All tumors received a single treatment. The median time from radiation segmentectomy to transplantation was 206 days (range, 58-550 days). Objective response per Modified Response Evaluation Criteria in Solid Tumors (mRECIST) was 92% (complete response, 76%; partial response, 16%). A total of 68% (n = 25) of tumors demonstrated ≥99% pathologic necrosis. Complete pathologic necrosis was present in 53% and 75% of tumors treated with >190 Gy (n = 18) and >500 Gy (n = 8) single-compartment Medical Internal Radiation Dose, respectively. Complete response per mRECIST, posttreatment angiosome T1 hypointensity, dose >190 Gy, microsphere specific activity >297 Bq, and a longer time between treatment and transplant were associated with ≥99% tumor necrosis (P < .05). No posttransplant tumor recurrences occurred within a median follow-up of 604 days (range, 138-1,223 days).

CONCLUSIONS

Radiation segmentectomy can serve as an ablative modality for the treatment of HCC prior to liver transplant.

A multi-institutional review of endovenous thermal ablation of the saphenous vein finds male sex and use of anticoagulation are predictors of long-term failure

BACKGROUND

To review long-term outcomes and saphenous vein (SV) occlusion rate after endovenous ablation (EVA) for symptomatic varicose veins.

METHODS

A review of our EVA database (1998-2018) with at least 3-years of clinical and sonographic follow-up. The primary end point was SV closure rate.

RESULTS

542 limbs were evaluated. 358 limbs had radiofrequency and 323 limbs had laser ablations; 542 great saphenous veins (GSV), 106 small saphenous veins (SSV) and 33 anterior accessory saphenous veins (AASV) were treated. Follow-up was 5.6 ± 2.3 years; 508 (74.6%) veins were occluded, 53 (7.8%) partially occluded and 120 (17.6%) were patent. On multivariable Cox regression analysis, male sex (HR 1.6, 95% CI [0.46-018], p = 0.012) and use anticoagulation (HR 2.0, 95% CI [0.69-0.34], p = 0.044) were predictors of long-term failure. On Kaplan-Meier curve, we had an 86.3% occlusion rate.

CONCLUSION

Our experience revealed a 5-year closure rate of 86.3%. Ablations have satisfactory occlusion rate.

Albumin-bilirubin grade as a prognostic indicator for patients with non-hepatocellular primary and metastatic liver malignancy undergoing Yttrium-90 radioembolization using resin microspheres

Background

Studies have shown that the albumin-bilirubin (ALBI) grade can be a superior prognosticator for patients undergoing Yttrium-90 (Y90) glass microsphere radioembolization for hepatocellular carcinoma (HCC) compared to the Child-Pugh (CP) scoring system. Less is known about the applicability of this score in non-hepatocellular malignancies using Y90 resin microspheres. This study evaluates the ALBI grade's ability to predict overall survival and biochemical toxicity in patients undergoing resin Y90 radioembolization and body surface area dosimetry (BSA) for non-hepatocellular primary and metastatic liver malignancies compared to the CP class and Model for End-Stage Liver Disease (MELD) score.

Methods

A retrospective review of patients with intrahepatic metastatic colorectal and neuroendocrine cancers and cholangiocarcinoma undergoing resin radioembolization from 2006-2015 at a single tertiary medical center was performed. ALBI, MELD, and CP scores were compared and correlated with biochemical toxicity and overall survival.

Results

There was a significant difference in overall survival between CP class A and class B liver function (P=0.04) for the entire patient cohort. ALBI grade (P=0.36) and MELD score (P=0.19) were not independently associated with survival. When stratified by CP class, the ALBI grade revealed a trend for survival difference in CP class B (P=0.05). Baseline ALBI grade was associated with post-procedural albumin reduction (P=0.01) and bilirubin elevation (P=0.007).

Conclusions

ALBI grade predicted post-procedural biochemical toxicity, but did not predict survival after resin radioembolization of non-hepatocellular liver malignancies using BSA dosimetry. Given the heterogeneity of this study population, dedicated prospective analyses are required.

Increasing Yttrium-90 Dose Conformality Using Proximal Radioembolization Enabled by Distal Angiosomal Truncation for the Treatment of Hepatic Malignancy

PURPOSE

To evaluate safety and feasibility of improving radiation dose conformality via proximal radioembolization enabled by distal angiosomal truncation where selective administration was not practical.

MATERIALS AND METHODS

Hepatic malignancies treated via angiosomal truncation between January 2017 and March 2019 were retrospectively evaluated. Thirty-three patients (8 women, 25 men; mean age, 62.2 y; range, 36-78 y) underwent 39 treatments. Of treatments, 74.3% (n = 29) were for hepatocellular carcinomas, 10.2% (n = 4) were for cholangiocarcinomas, and 15.4% (n = 6) were for metastatic tumors (1 colorectal adenocarcinoma, 1 pancreatic adenocarcinoma, 3 melanomas, and 1 endometroid carcinoma). Truncation was achieved using temporary embolic devices including a microvascular plug, detachable coil, gelatin slurry, and balloon microcatheter, after which proximal radioembolization was performed. Range of treatment activity was 0.47-5.75 GBq. Technetium-99m macroaggregated albumin and bremsstrahlung single photon emission computed tomography (CT)/CT threshold analysis was conducted to delineate and compare distribution of activity within the treatment angiosome before and after radioembolization.

RESULTS

Dosimetric analysis of 14 patients demonstrated a significant reduction in nontarget liver radiation exposure at 5, 20, and 40% thresholds (P = .002, P = .001, and P = .008, respectively). There were no grade 3 or higher adverse events. There was no significant change in Albumin-Bilirubin grade and Eastern Cooperative Oncology Group Performance Status (P = .09 and P = .74) before and 3 months after the procedure. Truncated arteries were patent on subsequent angiography in 11 cases and on MR angiography or CT angiography in 38 of 39 cases.

CONCLUSIONS

Proximal radioembolization enabled by distal angiosomal truncation is safe and decreases nontarget parenchymal radioembolization dose in cases not amenable to selective administration.

Transchondral access for irreversible electroporation of hepatocellular carcinoma

Ablative treatment for hepatocellular carcinoma is standard of care in selected settings and is endorsed by international societal guidelines. Centrally located hepatocellular carcinoma are difficult to treat due to their proximity to vasculature and central bile ducts. Irreversible electroporation is a nonthermal ablation modality that has been shown to preserve the extracellular matrix and is less likely to damage structures such as bile ducts and is not susceptible to vascular heat sink. Successful irreversible electroporation requires the parallel placement of probes which can be prevented by ribs or the sternum. This case report describes the use of the coaxial bone biopsy system to enable transchondral access and facilitate parallel placement of probes during irreversible electroporation IRE for the treatment of hepatocellular carcinoma.

Endovascular Treatment of Aortohepatic Conduit Stenosis Following Liver Transplant

BACKGROUND

Aortohepatic conduits (AHCs) are valuable alternatives when conventional hepatic artery anastomoses are not possible. However, AHCs have earlier and higher occlusion rates and reduced graft and patient survival. While endovascular therapy is safe and effective for conventional anastomotic stenoses, data on AHC stenoses are limited. This study reviewed outcomes for endovascular management of AHC stenosis at a single liver transplant center.

METHODS

A retrospective review of a prospectively maintained database was performed on the endovascular management of AHC stenosis between January 1, 2000, and December 31, 2016. Medical records, laboratory data, and imaging were analyzed for technical and hemodynamic success, primary and assisted primary patency, and patient and graft survival.

RESULTS

Seven patients underwent angioplasty a median of 142 days after transplant, and 2 required reintervention. The primary patency rate was 67% at 6 months and 22% at 1 year. The assisted primary patency rate was 83% at 6 months and 42% at 1, 3, and 5 years. Patient and graft survival were 86% at 6 months and 71%, 57%, and 38% at 1, 3, and 5 years, respectively. Four conduits were patent at last follow-up. There were no major adverse events after angioplasty. One reintervention was complicated by acute AHC thrombosis after stenting, causing biliary necrosis, sepsis, and death. There was no 30-day mortality, retransplant, or surgical revascularization because of endovascular intervention.

CONCLUSIONS

Endovascular treatment of AHC stenosis appears to be safe with a high technical success rate but lower long-term patency than standard hepatic arterial anastomoses.

Renal artery injury during inferior vena cava filter removal with endobronchial forceps

Retrieval of tip-embedded inferior vena cava filters using endobronchial forceps is a well-described technique. The tip of dorsally tilted filters may be in proximity to the right renal artery, increasing the risk of arterial injury during retrieval. We present one case that illustrates renal artery injury requiring emergent stent graft repair. The three subsequent cases illustrate techniques that avoid renal artery injury using a femoral and jugular approach with the assistance of an arterial fiducial wire. Renal artery injury is a potential complication during retrieval of filters using endobronchial forceps that can be prevented with careful planning.

Organizing Pneumonia Induced by Ablative Radioembolization for the Treatment of Hepatic Metastatic Renal Cell Carcinoma

Organizing pneumonia is a recognized complication after external beam radiotherapy of breast and lung cancer but has not been described after radioembolization. A 67-year-old female who underwent ablative trans-arterial radioembolization for the treatment of hepatic metastatic renal cell carcinoma adjacent to the diaphragm presented with computed tomography findings of asymptomatic organizing pneumonia in the lower lobes. A follow-up computed tomography 8 months after conservative management demonstrated near-total resolution of the previous pulmonary parenchymal disease. The patient continues to remain asymptomatic and shows no evidence of residual tumor 10 months after radioembolization.

Individualized Ablation of Hepatocellular Carcinoma: Tailored Approaches across the Phenotype Spectrum

Ablation is now recommended by international guidelines for the definitive treatment of hepatocellular carcinoma (HCC). Extensive clinical studies have demonstrated outcomes comparable to surgical resection with shorter hospital stays, decreased costs, and improved quality of life. Successful ablation requires complete treatment of both tumor and margin while preserving critical adjacent structures. HCC exhibits highly variable presentations in both anatomic involvement and biology which have significant implications on choice of ablative therapy. There are now abundant ablation modalities and adjunctive techniques which can be used to individualize ablation and maximize curative results. This article provides a patient-centered summary of approaches to HCC ablation in the context of patient performance, hepatic reserve, tumor phenotype and biology, intra- and extrahepatic anatomy, and ablation technology.

Association of Frontal and Lateral Facial Attractiveness

Importance

Despite the large number of studies focused on defining frontal or lateral facial attractiveness, no reports have examined whether a significant association between frontal and lateral facial attractiveness exists.

Objectives

To examine the association between frontal and lateral facial attractiveness and to identify anatomical features that may influence discordance between frontal and lateral facial beauty.

Design, Setting, and Participants

Paired frontal and lateral facial synthetic images of 240 white women (age range, 18-25 years) were evaluated from September 30, 2004, to September 29, 2008, using an internet-based focus group (n = 600) on an attractiveness Likert scale of 1 to 10, with 1 being least attractive and 10 being most attractive. Data analysis was performed from December 6, 2016, to March 30, 2017. The association between frontal and lateral attractiveness scores was determined using linear regression. Outliers were defined as data outside the 95% individual prediction interval. To identify features that contribute to score discordance between frontal and lateral attractiveness scores, each of these image pairs were scrutinized by an evaluator panel for facial features that were present in the frontal or lateral projections and absent in the other respective facial projections.

Main Outcomes and Measures

Attractiveness scores obtained from internet-based focus groups.

Results

For the 240 white women studied (mean [SD] age, 21.4 [2.2] years), attractiveness scores ranged from 3.4 to 9.5 for frontal images and 3.3 to 9.4 for lateral images. The mean (SD) frontal attractiveness score was 6.9 (1.4), whereas the mean (SD) lateral attractiveness score was 6.4 (1.3). Simple linear regression of frontal and lateral attractiveness scores resulted in a coefficient of determination of r2 = 0.749. Eight outlier pairs were identified and analyzed by panel evaluation. Panel evaluation revealed no clinically applicable association between frontal and lateral images among outliers; however, contributory facial features were suggested. Thin upper lip, convex nose, and blunt cervicomental angle were suggested by evaluators as facial characteristics that contributed to outlier frontal or lateral attractiveness scores.

Conclusions and Relevance

This study identified a strong linear association between frontal and lateral facial attractiveness. Furthermore, specific facial landmarks responsible for the discordance between frontal and lateral facial attractiveness scores were suggested. Additional studies are necessary to determine whether correction of these landmarks may increase facial harmony and attractiveness.

Level of Evidence

NA.

Percutaneous Pulmonary Embolism Thrombectomy and Thrombolysis: Technical Tips and Tricks

Catheter-directed therapy (CDT) is now acknowledged as a treatment option for select patients with acute massive or submassive pulmonary embolism (PE), and more patients are being considered for CDT if there is available expertise. Therefore, interventionalists should be aware of the variety of catheter-based treatment options, specific pitfalls to avoid during therapy, and the appropriate treatment endpoints. This article reviews currently available techniques and protocols for treating acute massive and submassive PE, with tips to safely and successfully perform percutaneous PE interventions.

A Quantitative Approach to Determining the Ideal Female Lip Aesthetic and Its Effect on Facial Attractiveness

Importance

Aesthetic proportions of the lips and their effect on facial attractiveness are poorly defined. Established guidelines would aid practitioners in achieving optimal aesthetic outcomes during cosmetic augmentation.

Objective

To assess the most attractive lip dimensions of white women based on attractiveness ranking of surface area, ratio of upper to lower lip, and dimensions of the lip surface area relative to the lower third of the face.

Design, Setting, and Participants

In phase 1 of this study, synthetic morph frontal digital images of the faces of 20 white women ages 18 to 25 years old were used to generate 5 varied lip surface areas for each face. These 100 faces were cardinally ranked by attractiveness through our developed conventional and internet-based focus groups by 150 participants. A summed ranking score of each face was plotted to quantify the most attractive surface area. In phase 2 of the study, 4 variants for each face were created with 15 of the most attractive images manipulating upper to lower lip ratios while maintaining the most attractive surface area from phase 1. A total of 60 faces were created, and each ratio was ranked by attractiveness by 428 participants (internet-based focus groups). In phase 3, the surface area from the most attractive faces was used to determine the total lip surface area relative to the lower facial third. Data were collected from March 1 to November 31, 2010, and analyzed from June 1 to October 31, 2016.

Main Outcomes and Measures

Most attractive lip surface area, ratio of upper to lower lip, and dimension of the lips relative to the lower facial third.

Results

In phase 1, all 100 faces were cardinally ranked by 150 individuals (internet-based focus groups [n = 130] and raters from conventional focus groups [conventional raters] [n = 20]). In phase 2, all 60 faces were cardinally ranked by 428 participants (internet-based focus groups [n = 408] and conventional raters [n = 20]). The surface area that corresponded to the range of 2.0 to 2.5 × 104 pixels represented the highest summed rank, generating a pool of 14 images. This surface area was determined to be the most attractive and corresponded to a 53.5% increase in surface area from the original image. With the highest mean and highest proportions of most attractive rankings, the 1:2 ratio was deemed most attractive. Conversely, the ratio of 2:1 was deemed least attractive, having the lowest mean at 1.61 and the highest proportion of ranks within 1 with 310 votes (72.3%).

Conclusions and Relevance

Using a robust sample size, this study found that the most attractive lip surface area represents a 53.5% increase from baseline, an upper to lower lip ratio of 1:2, and a surface area equal to 9.6% of the lower third of the face. Lip dimensions and ratios derived in this study may provide guidelines in improving overall facial aesthetics and have clinical relevance to the field of facial plastic surgery.

Level of Evidence

NA.

Technical and Anatomic Factors Influencing the Success of Inferior Vena Caval Stent Placement for Malignant Obstruction

PURPOSE

To evaluate the outcomes of inferior vena cava (IVC) stent placement for malignant obstruction and to identify anatomic and procedural factors influencing technical and clinical success.

MATERIALS AND METHODS

A total of 57 patients (37 male, 20 female; age range, 22-86 y) underwent 62 IVC stent placement procedures using 97 stents (47 Wallstents, 15 S.M.A.R.T. stents, 18 Wallflex stents, 17 others) from 2005 to 2016 for malignant IVC obstruction caused by hepatic metastases (n = 22; 39%), primary hepatic malignancy (n = 16; 28%), retroperitoneal metastases (n = 16; 28%), or other primary malignancy (n = 5; 9%). Presenting symptoms included lower-extremity edema (n = 54; 95%), ascites (n = 28; 50%), and perineal edema (n = 14; 25%). Sixteen percent (n = 10) and 10% (n = 6) of the procedures involved tumor and bland thrombus, respectively.

RESULTS

Stent placements resulted in 100% venographic patency and significantly decreased pressure gradients (P < .0001). Lower-extremity swelling, perineal swelling, and abdominal distension improved within 7 days in 83% (35 of 42), 100% (9 of 9), and 40% (6 of 15) of patients, respectively, and at 30 days after the procedure in 86% (25 of 29), 89% (8 of 9), and 80% (4 of 5) of patients, respectively. Increased pre- and post-stent placement pressure gradients were associated with worse outcomes. A 4% stent misplacement rate (4 of 97) was related to the use of Wallstents with caudal stent tapering, asymmetric deployment superior to the obstruction, suprahepatic IVC involvement, and decreased stent adherence to the IVC wall as a result of local mechanical factors.

CONCLUSIONS

Stent placement is reliable, rapid, and durable in improving malignant IVC syndrome. Understanding of technical and anatomic factors can improve accuracy and avoid complications of stent misplacement.

Morphometric facial analysis: a methodology to create lateral facial images

INTRODUCTION

Currently, the majority of research in facial analysis using computational morphing methods focuses exclusively on analysis of frontal facial projections. Lateral facial morphing analysis has not been extensively investigated, and landmark features critical to specify registry points are unknown. This study aims to (1) determine the quantity of registry points (RP) required to create realistic lateral faces and (2) determine key facial registry point landmarks required to create synthetic lateral faces.

METHOD

36 synthetic lateral faces with a 50 to 250 RP were created to determine the ideal quantity of RP to create a realistic lateral image; ear, eyebrow, eye, nose, lips, hairline, facial outline, and overall outline were evaluated by an expert panel of seven evaluators using a 1 to 5 point Lickert scale rating system.

RESULT

ANOVA single-variable analyses revealed significant differences when comparing templates of 200 and 250 RP with 50 and 100 RP templates (p < 0.05). Furthermore, analysis of all key landmark areas of the face indicated significant differences between different registry points except for 200 and 250 registry point markers. Kruskal-Wallis statistical analysis revealed the landmarks varied significantly from 50 to 200 RP,but had no significance with 200 and 250 RP.

CONCLUSION

The most ideal quantity of RP used for the creation of realistic lateral faces was in the range of 200 RP. Defined lateral facial registry point landmarks generated successful realistic faces.

The efficacy of hepatic 90Y resin radioembolization for metastatic neuroendocrine tumors: a meta-analysis

(90)Y resin radioembolization is an emerging treatment in patients with liver-dominant metastatic neuroendocrine tumors (mNETs), despite the absence of level I data. The aim of this study was to evaluate the efficacy of this modality in a meta-analysis of the published literature.

METHODS

A comprehensive review protocol screened all reports in the literature. Strict selection criteria were applied to ensure consistency among the selected studies: human subjects, complete response data with time interval, resin microspheres, more than 5 patients, not a duplicate cohort, English language, and separate and complete data for resin-based (90)Y treatment of mNET if the study included multiple tumor and microsphere types. Selected studies were critically appraised on 50 study criteria, in accordance with the research reporting standards for radioembolization. Response data (Response Evaluation Criteria in Solid Tumors) were extracted and analyzed using both fixed and random-effects meta-analyses.

RESULTS

One hundred fifty-six studies were screened; 12 were selected, totaling 435 procedures for response assessment. Funnel plots showed no evidence of publication bias (P = 0.841). Critical appraisal revealed a median of 75% of desired criteria included in selected studies. Very high between-study heterogeneity ruled out a fixed-effects model. The random-effects weighted average objective response rate (complete and partial responses, CR and PR, respectively) was 50% (95% confidence interval, 38%-62%), and weighted average disease control rate (CR, PR, and stable disease) was 86% (95% confidence interval, 78%-92%). The percentage of patients with pancreatic mNET was marginally associated with poorer response (P = 0.030), accounting for approximately 23% of the heterogeneity among studies. The percentage of CR and PR correlated with median survival (R = 0.85; P = 0.008).

CONCLUSION

This meta-analysis confirms radioembolization to be an effective treatment option for patients with hepatic mNET. The pooled data demonstrated a high response rate and improved survival for patients responding to therapy.

The Persian woman's face: a photogrammetric analysis

BACKGROUND

The aim of this study was to establish normative quantitative anthropometric measurements of the Persian woman's face and assess differences from established North American White women's measurements.

METHODS

Standard photographs (frontal, left lateral, and base views) of 107 Persian women volunteers (both parents of Persian ancestry) between the ages of 18 and 40 were digitally acquired. Twenty-six standard anthropometric measurements were obtained using Adobe Photoshop. The results were compared with those previously published for North American White women using an unpaired t test with differences being considered significant if p<0.05.

RESULTS

A statistically significant difference was found between Persian women and North American White women in 18 of 26 anthropometric measurements.

CONCLUSION

The anthropometric differences between Persian women and North American White women reflect fundamental differences in the osseochondrous scaffold and soft tissue covering of the face. These differences partially account for the disharmony and loss of ethnic identity that occurs when surgery is planned using classical canons. For patients wishing to maintain their ethnic features following aesthetic surgery, access to ethnicity-specific normative anthropometric data will help guide the surgeon to achieve this goal.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

Nonoperative treatment of proximal humerus fractures: a systematic review

BACKGROUND

Proximal humerus fractures are common in the setting of osteopenia and osteoporosis and can often be treated nonoperatively. There are few studies that evaluate the long-term outcomes of nonoperative treatment of these fractures. We performed a systematic review of the literature to examine the results of nonoperative treatment of proximal humerus fractures.

METHODS

The PubMed search engine and EMBASE database were used. Inclusion criteria were: 1) proximal humerus fractures resulting from trauma; 2) age older than 18 years; 3) more than 15 patients in the study; 4) greater than 1 year follow-up; 5) at least one relevant functional outcome score; and 6) a quality outcome score of at least a 5 of 10 according to previously published scoring system.

RESULTS

We identified 12 studies that included 650 patients with a mean age of 65.0 years (range, 51-75 years) and a mean follow-up of 45.7 months (range, 12-120 months). There were 317 one-part fractures, 165 two-part fractures, 137 three-part fractures, and 31 four-part fractures. The rate of radiographic union was 98% and the complication rate 13%. The average range of motion reported in five studies was 139° forward flexion, 48° external rotation, and 52° internal rotation. The average Constant score reported in six studies was 74 (range, 55-81). Varus malunion was the most common complication reported, whereas avascular necrosis was uncommon (13 cases).

CONCLUSIONS

We conclude that our systematic review of the literature on the nonoperative treatment of proximal humerus fractures demonstrates high rates of radiographic healing, good functional outcomes, and a modest complication rate.

Nasal tip projection and facial attractiveness

OBJECTIVES/HYPOTHESIS

Six nasal tip projection (NTP) ratios from Goode, Simons, Baum, Powell, and Crumley guide clinical and academic practice on quantifying NTP, but none have been empirically correlated with facial attractiveness. This study's objectives were to determine: 1) if there is a correlation between these ratios and facial attractiveness; and 2) which of the six ratios has the greatest linkage to overall facial attractiveness.

STUDY DESIGN

Basic research study.

METHODS

There were 300 digital portraits of women (ages 18-25 years) randomly paired and morphed to create 300 synthetic lateral facial images rated by 78 raters in the community. NTP ratios were measured in each portrait.

RESULTS

None of the ratios correlated with facial attractiveness. For the Baum, Powell, and Simons ratio, facial attractiveness increased as NTP deviated 1 and 2 standard deviations from the ideal, whereas facial attractiveness decreased as NTP deviated from the Goode and Crumley ideal ratios. The most attractive faces had NTP ratios consistent with previous expert opinion findings.

CONCLUSIONS

To our knowledge, this is the first study to empirically correlate these six landmark NTP ratios with facial attractiveness. Although there was no correlation with any of the six ratios, the ideal ratios proposed by Goode and Crumley impacted facial aesthetics the most. Although the ideal ratios are useful in establishing rhinoplasty guidelines, they should only be used as a part of the management in achieving an aesthetic face on the whole, as they may not be robust enough to correlate with overall facial attractiveness.

A systematic review of locking plate fixation of proximal humerus fractures

PURPOSE

Technique for the fixation of two, three, and four part proximal humerus fractures has rapidly shifted towards the use of specially contoured proximal humerus locking plates. The purpose of this study is to evaluate the short to medium term functional results and common complications associated with the fixation of proximal humerus fractures with locking plates.

METHODS

The PubMed and EMBASE databases were used to perform a systematic review of the English literature to assess the functional results and complications associated with proximal humerus locking plates. Our inclusion criteria were proximal humerus fracture due to trauma (excluding pathologic fractures), patients greater than 18 years of age, more than 15 patients in the study or subgroup of interest, at least 18 months follow-up, at least one relevant functional outcome score, and quality outcome score of at least 5/10. Studies that did not meet these criteria were excluded. All institutional, author, and journal information was concealed to minimize reviewer bias.

RESULTS

Twelve studies including 514 patients met the inclusion criteria. At most recent follow-up patients achieved a mean Constant score of 74 and a mean DASH score of 27. The overall rate of complications was 49% including varus malunion, 33% excluding varus malunion, and reoperation rate was 14%. The most common complications included varus malunion 16%, AVN 10%, screw perforation of the humeral head into the joint 8%, subacromial impingement 6%, and infection 4%.

DISCUSSION

Fixation of proximal humerus fractures with proximal humerus locking plates is associated with a high rate of complications and reoperation. Further study is needed to determine what technical errors and patient characteristics are risk factors for failure of this now common fixation technique.

A new approach in determining lateral facial attractiveness

INTRODUCTION

The current literature on facial attractiveness focuses on anterior-posterior facial portraits, with lateral facial analysis limited to comparing facial attractiveness scores with various facial measurements. Here we use a novel approach to more rigorously study lateral facial attractiveness by combining morphing software and a genetic algorithm with web-based facial attractiveness scoring to evolve attractive lateral facial images.

OBJECTIVE

The objectives of this study were to: 1) identify the key lateral facial landmarks that produce realistic lateral facial images; and 2) determine if a genetic algorithm combined with morphing software can progressively evolve lateral facial attractiveness.

METHODS

A cohort of lateral facial portraits were selectively paired by a genetic algorithm biased towards more attractive faces, and "bred" with morphing software to create a cohort of faces more attractive than the original. By repeating this process facial attractiveness was "evolved" through several cohorts.

RESULTS

Key facial landmarks are: trichion to glabella, nasion to tip of nose, subnasale to labrale inferius, and pogonion to menton. Facial attractiveness scores increased in each successive cohort.

CONCLUSION

Using these landmarks and methodologies, realistic lateral facial portraits were created and progressively increased in facial attractiveness. This technique is a robust alternative to traditional approaches in the analysis of lateral facial attractiveness.

A web-based method for rating facial attractiveness

OBJECTIVES/HYPOTHESIS

To determine if facial attractiveness scores from a novel Internet-based facial attractiveness rating method correlate with those from the traditional focus group rating method, and whether this method can be an alternative for rating and evaluating facial attractiveness.

STUDY DESIGN

Basic research study.

METHODS

Eighty facial portraits were posted on a commercial Internet-based facial rating website to obtain facial attractiveness scores. These scores were correlated and compared with traditional focus group scores.

RESULTS

In 21 days an average sample size of 857 raters were recruited and the attractiveness scores reached a stable mean on the Web. There was a strong correlation (0.90) and attractiveness score quartile match between the Internet-based and traditional focus group scores, with the most attractive and unattractive faces having the highest correlation and quartile match. The inter-rater variability of the Internet-based method was low (P = .82).

CONCLUSIONS

The Internet-based method can be an effective alternative to the traditional live focus group method of evaluating facial attractiveness. It also has five main advantages: 1) profoundly increases rater count; 2) increases rate of data accrual and analysis; 3) results are reproducible; 4) eliminates logistical and monetary obstacles; and 5) enables the experimenter to sweep broad demographics, acquire background data from raters, and locate raters with specific expertise.

Single-stage reconstruction of a devastating antebrachial injury with brachial artery, median nerve, and soft tissue deficit: a case report and review of the literature

OBJECTIVE

We present a case of a 31-year-old man who fell through a skylight sustaining a deep laceration injury to his dominant arm. A single-stage radial artery flow-through free flap and cabled sural nerve graft for reconstruction of a complex antebrachial defect involving skin, soft tissue, muscle, brachial artery, and median nerve was performed. A technical description of the case and review of the literature are described.

METHODS

Traumatic injuries to the arm and antecubital fossa often lead to devastating outcomes. Advances in microsurgical technique as well as improved skin and dermal substitutes have allowed improved outcomes as well as shorter hospital stays. In this case, surgical treatment involved microsurgical reconstruction of the brachial artery with a radial artery flow-through flap and a single-stage donor-site closure with an Integra dermal matrix template and split-thickness skin graft.

RESULTS

Successful vascular flow and soft tissue coverage were performed with successful salvage of the limb.

CONCLUSION

A single-stage reconstruction versus a multistage, delayed reconstruction of a devastating arm injury with a radial forearm flow-through flap and single-stage closure with Integra and autologous skin graft can provide a safe, effective, and clinically satisfactory outcome.

Surgical treatment options for subacute ischemia of the hand: case report and literature review

PURPOSE

The most effective surgical approach to the treatment of digital ischemia has not yet been established. The purpose of this study is to review currently accepted options for revascularization in acute and chronic settings of digital ischemia, and to augment this discussion by describing the approach of our surgical team in a unique case of subacute ischemia.

OPERATIVE TECHNIQUE

To restore blood flow to a patient's ischemic hand, we performed a microvascular reconstruction, using a reverse interpositional vein graft with 3 anastomoses: the ulnar artery was used for inflow and the superficial palmar arch and the common digital artery were used for outflow.

RESULTS

The patient experienced immediate postoperative pain relief. Blood flow was restored, which prevented digital amputation. The graft remained patent at 18 months' follow-up and the patient exhibited normal motor and sensory function.

CONCLUSIONS

Surgical reconstruction of the hand is a viable treatment option for carefully selected patients presenting with subacute digital ischemia. Other medical and surgical techniques have been described in the recent literature, but further study is needed to determine the long-term success of newer microsurgical interventions.