The Use of Advanced Three-Dimensional Computed Tomography During Simple and Complex Endovascular Aortic Aneurysm Repairs

OBJECTIVES

Endovascular aneurysm repair (EVAR) success depends on imaging technology both in the planning and operative phases. Endovascular repair requires intravenous contrast and radiation exposure to the patient as well as radiation exposure to the operator. Recent developments in imaging technology attempt to merge preoperative imaging with intraoperative imaging to improve the efficiency and accuracy of EVAR. The Cydar 3D imaging system combines the preoperative and intraoperative imaging during the operation. We aim to investigate the use of the Cydar 3D imaging system during EVAR compared to conventional methods.

METHOD

Retrospective review of all patients undergoing an EVAR at a single quaternary vascular center from 2019-2023 was collected. This cohort was divided into two groups: (1) Repair using Cydar 3D imaging or (2) Repair without Cydar 3D imaging. Overall, 138 unique patients were identified with 27 operations using Cydar 3D imaging and 111 operations without Cydar 3D imaging. We performed a 1-to-1 propensity score - matched analysis using nearest-neighbor matching for variables including age, case urgency, and if the case was performed in the operative room or interventional radiology room. A match occurred when a patient in the Cydar 3D imaging group had an estimated score within 0.01 standard deviations of a patient in the control group. From this we paired 27 from each cohort for a total of 54 patients. Demographic data included length of stay (LOS) in days, contrast volume (ml), Fluoroscopy time (min), procedure length (mins), mortality, blood loss (ml). Univariate analyses were performed and a p-value less than 0.05 was considered statistically significant.

RESULTS

A total of 54 vascular patients were analyzed: 27 without the Cydar 3D imaging and 27 with the Cydar 3D imaging. In the univariate analysis there was no statistical difference in the average length of stay (6.4 days ± 11.76 vs. 4.1 ± 6.03, p = 0.372), aneurysm size (5.9 ± 1.4 vs. 5.9 ± 1.2, p=0.88), contrast volume in mL (91.3 ± 47.0 vs. 91.1-33.49, p=9.88), fluoroscopy time in mins (20.2±17.2 vs. 19.5±19.4, p=0.89) , procedure length (299.3±177.9 vs. 353±191.98, p=0.279), blood loss in mL (513.8±791 vs. 353±191.98, p=0.594). There was an increase in reintervention for endoleaks in the group with use of Cydar 3D imaging (0 vs 6, p=0.043). A sub-analysis of patients undergoing physician modified EVARs did show a 15% reduction in the contrast volume used.

CONCLUSION

The use of 3D imaging technology has the potential to increase the safety of EVAR to both patients and operators. In our study we did not find any difference in standard EVARs however there was a contrast use decrease in physician modified EVARs. Further studies will need to be performed to determine the realized benefit from performing EVARs using this new technology.

Tracheal ulcer development from high volume, low-pressure cuffed endotracheal tubes

INTRODUCTION

Iatrogenic injury to the larynx, particularly the vocal cords from prolonged intubation, has been well-studied; however, tracheal injuries are rarely reported. This study investigates the effectiveness of cuffed, high-volume, low-pressure endotracheal tubes in preventing the development of tracheal ulcers in intubated subjects.

METHODS

A retrospective, IRB-approved review was performed on 1355 subjects who underwent percutaneous tracheostomy from 2002 to 2018. The presence and severity of tracheal ulcers were collected using documentation and photos during percutaneous tracheostomy placement. Primary outcome measures included: the length of time on a ventilator until tracheostomy (LOVT), length of hospitalization (LOH), and mortality in relationship to the severity of the tracheal injury. Data was reported as n (%) and median (IQR). The differences in means between groups were analyzed by ANOVA and Chi-square test with an alpha of 0.05.

RESULTS

206 subjects met the inclusion criteria; 65 subjects had an absence of tracheal injury, and 141 subjects developed tracheal ulcers. Subjects with tracheal ulcers were grouped by the following severity scale: no ulcer; mild ulcer (minimal mucosal erosion with exudate); moderate ulcer (mucosal erosion); and severe (tracheal ring exposure). There were no statistically significant differences in age (p = 0.99), gender (p = 0.83), BMI (p = 0.44), LOH (p = 0.88), LOVT (p = 0.93), and mortality (p = 0.306) between subjects with differing severity of ulcers. The average annual incidence of clinically significant ulcers (moderate and severe) was 2.2 %.

CONCLUSIONS

The lack of statistical correlation between the duration of intubation and tracheal ulcer severity, along with a low annual incidence of tracheal ulcers, supports the improved safety of high-volume, low-pressure cylindrical, cuffed endotracheal tubes. This study is among the first to specifically focus on injuries at the level of the cuff and tip of endotracheal tubes with implications in preventive measures and potential product design changes.

The Impact of Computed Tomography Scans on the Management and Wait Times in Perianal Abscess Diagnoses

Background Diagnosis and management of perianal abscesses (PAA) are based on history and clinical examination. Imaging is not indicated except in complicated cases, as determined by the surgical team. The monetary, ionizing radiation, and resource utilization costs of a computed tomography (CT) scan in the emergency room must be considered when used for diagnostic purposes of PAAs. Methods A retrospective analysis of 129 patients diagnosed with a diagnosis of PAA between 2015-2020 was performed. The primary endpoints included length of stay, CT performed, time from patient presentation to CT, and CT scan completion prior to surgical consultation. Data is reported as n (%) or median (IQR). Results Of the 129 patients diagnosed with PAA, 81 underwent CT, and 48 did not. General surgery was consulted in 88% of cases. There were no statistically significant differences in age (p=0.562), sex (p=0.531), or ethnicity (p=0.356). The median hospitalization time was two days when CT was performed (p=0.001). The median time elapsed from presentation to the emergency department and CT scan performed was 16 hours (p=0.001). CT scans were ordered before the surgical consultation in 65% of cases (p=0.001) and 17% after a surgical consultation was placed (p=0.009). Conclusion Performing CT scans prior to surgical evaluation for the diagnosis of PAA is not a responsible practice. The cost, resources, and radiation exposure must be considered. This study demonstrated that more CT scans are ordered prior to surgical consultation for PAA, resulting in a prolonged wait time in the emergency department.

A unique finding of the basilar artery

Variants of the posterior intracranial circulation are important for surgeon, interventionalists and radiologists. Herein, a unique configuration of the basilar artery is reported. A 54-year-old man with a history of COPD, hypothyroidism, smoking, and hyperlipidemia presented to an outside institution with nausea, confusion, altered mental status, and ataxia. The patient was evaluated for stroke. Imaging revealed rotation of the basilar apex of 180 degrees, fetal configuration of the posterior communicating artery, right posterior cerebral artery filling from the left vertebral artery, and duplication of the left and right superior cerebellar arteries. The patient continued to deteriorate neurologically and MRI revealed multifocal and symmetric signal abnormalities in the brain stem, thalami, basal ganglia, and hippocampi. The differential diagnosis included acute disseminated myeloencephalitis. Despite plasma exchange and steroid therapy, the patient died a few days later. This case report demonstrates a rare variation of the basilar apex.

An Interesting Civilian Case of Complex Maxillofacial Trauma Due to Target Fragmentation Following Bullet Impact and Review of the Branches of the Maxillary Artery

Serious morbidity and mortality for the operator and bystanders are associated with a lack of knowledge and failure to utilize appropriately manufactured targets. The management of firearm-related facial trauma is challenging and requires rapid intervention from a multidisciplinary team. We present a case of penetrating facial trauma secondary to the fragmentation of a homemade target. We highlight how firearm operators can optimize safety by matching ballistics with target selection and review pertinent vascular structures, including the terminal branches of the external carotid artery and branches of the maxillary artery. This case demonstrates that trauma physicians must be well-versed with complex maxillofacial anatomy and multimodal approaches to hemostasis.

Gerber's Ligament-A Forgotten Structure of the Craniocervical Junction

BACKGROUND

Ligaments of the craniocervical junction play a critical role in stabilizing this region. Gerber's ligament has more or less been forgotten and, to our knowledge, never studied.

METHODS

Dissection of the craniocervical junction was performed in 15 fresh frozen cadavers. In the prone position, the posterior elements of the upper cervical vertebrae and occiput were removed. After removing the contents of the spinal canal and posterior cranial fossa, the dura mater and tectorial membrane were reflected. The superior band of the cruciform ligament was reflected. When Gerber's ligament was identified, its attachments and morphometry were recorded. Lastly, Gerber's ligament was observed while range of motion of the craniocervical junction was performed.

RESULTS

Gerber's ligament was identified in 7 specimens (46.7%). This structure arose anteriorly from the junction of the superior band and transverse part of the cruciform ligament. Gerber's ligament was always found to be just deep to the superior band of the cruciform ligament but traveled more anteriorly to attach onto the posterior aspect of the dens approaching, but not attaching onto, its apex. Mean length was 11 mm, and mean width was 7 mm. Thickness of the ligament was 0.5-1.1 mm. The ligament was found to become taut with minimal rotation of the atlantoaxial joint and extension of the craniocervical junction.

CONCLUSIONS

A good understanding of all ligaments of the craniocervical junction is important to surgeons and physicians treating patients with injury to the upper cervical spine.

An Unusual Finding of the Hyoid Bone

The hyoid contributes to many biomechanical processes including swallowing. Additionally, the hyoid bone has been studied for over a century in an effort to catalog and categorize many observed biometric differences. This has led to the hyoid being a major structure involved in forensic pathology. In this paper, we discuss a very unusual finding of an adult female hyoid bone.

Henle's Ligament: A Comprehensive Review of Its Anatomy and Terminology over Almost One and a Half Centuries

Henle's ligament was first described by German physician and anatomist, Friedrich Henle, in 1871. This review article will cover Henle's original description of the ligament, historical changes in terminology, embryological studies of the ligament, and the clinical significance of Henle's ligament. This article has a particular focus on the variation in the terminology of this structure and the implications of this.