3D-CTA assisted anterolateral thigh lobulated perforator flap in repairing soft tissue defect of limb:11 cases report / 中华显微外科杂志

Objective To investigate the effectiveness of preoperative 3D-CTA in assisting the preparation of free thinned anterolateral thigh lobulated perforator flap with nerve in repairing soft tissue defect of limb. Methods Between February, 2010 and May, 2018, free super-thin anterolateral thigh lobulated perforator flap with nerve was transferred to repair soft tissue defect of limbs in 11 cases. There were 8 males and 3 females with an average age of 35 (range, 22-56) years.The defect area was 8.0 cm×11.0 cm-9.0 cm×23.0 cm. Preoperation CT scan of the free flap donor site was performed to obtain 3D images of the region with arterial blood supply by digital 3D reconstruction CT, and to determine the origin, direction, classification, length, diameter and the position of pedicle perforator.Postopera鄄tive regular followed-up was carried according to the Upper Limb Function Evaluation Trial Standards of Chinese Medical Association of Hand Surgery and Enneking Evaluation System. Results All 11 flaps survived. No vascular crisis happened.All 11 cases were followed-up for 3 to 12 (average, 5) months.The flaps were supple and elastic with near normal color.There was no bulkiness.Sensory function was recovered well and two point discrimination was 3.0-6.0 mm. According to the Upper Limb Function Evaluation of Upper Limb of Chinese Medical Association of Hand Surgery, the results were excellent in 1 case, good in 3 cases and fair in 1 case.The Enneking system was used to as鄄sesse the lower limbs recovery.The average score was 21, an average of 70% of limb function restored. Conclusion The free super-thin anterolateral thigh lobulated perforator flap with nerve offers advantages to the traditional antero鄄lateral thigh flap. The survived flaps are ideal in terms of covering limb defects and restoring functions. Preoperative 3D-CTA in the anterolateral thigh perforator flap transplantation is an accurate and useful method.It helps a safer and successful operation with optimal outcome.

3D-CTA assisted anterolateral thigh lobulated perforator flap in repairing soft tissue defect of limb: 11 cases report / 中华显微外科杂志

Objective@#To investigate the effectiveness of preoperative 3D-CTA in assisting the preparation of free thinned anterolateral thigh lobulated perforator flap with nerve in repairing soft tissue defect of limb.@*Methods@#Between February, 2010 and May, 2018, free super-thin anterolateral thigh lobulated perforator flap with nerve was transferred to repair soft tissue defect of limbs in 11 cases. There were 8 males and 3 females with an average age of 35 (range, 22-56) years. The defect area was 8.0 cm×11.0 cm-9.0 cm×23.0 cm. Preoperation CT scan of the free flap donor site was performed to obtain 3D images of the region with arterial blood supply by digital 3D reconstruction CT, and to determine the origin, direction, classification, length, diameter and the position of pedicle perforator. Postoperative regular followed-up was carried according to the Upper Limb Function Evaluation Trial Standards of Chinese Medical Association of Hand Surgery and Enneking Evaluation System.@*Results@#All 11 flaps survived. No vascular crisis happened. All 11 cases were followed-up for 3 to 12 (average, 5) months. The flaps were supple and elastic with near normal color. There was no bulkiness. Sensory function was recovered well and two point discrimination was 3.0-6.0 mm. According to the Upper Limb Function Evaluation of Upper Limb of Chinese Medical Association of Hand Surgery, the results were excellent in 1 case, good in 3 cases and fair in 1 case. The Enneking system was used to assesse the lower limbs recovery. The average score was 21, an average of 70% of limb function restored.@*Conclusion@#The free super-thin anterolateral thigh lobulated perforator flap with nerve offers advantages to the traditional anterolateral thigh flap. The survived flaps are ideal in terms of covering limb defects and restoring functions. Preoperative 3D-CTA in the anterolateral thigh perforator flap transplantation is an accurate and useful method. It helps a safer and successful operation with optimal outcome.

Repairing massive soft tissue defects of shank and foot with combined flaps with the help of 3D-CTA technique / 中华显微外科杂志

To explore the clinical value of repairing massive soft tissue defects of shank and foot with diverse combined flaps with the help of 3D-CTA technique. Methods From March, 2011 to May, 2018, 7 pa-tients with massive soft tissue defects (defect area:21 cm×14 cm-53 cm×16 cm) of shank and foot were treated with combined flaps, including free anterolateral thigh flaps(ALTP) combined with local transferred sural neurocuta-neous vascular flaps in 2 cases, free ALTP combined with local transferred supracondylar flap in 2 cases, free thora-co-umbilical flaps plus local transferred gastrocnemius muscular flaps in 1 case, and free ALTP plus free thoraco-um-bilical flap in 1 case.Free ALTP and free thoraco-umbilical flap respectively combined with double bridge flaps using the both ends of posterior tibial vessel from the healthy limb to form vascular pedicles in 1 case. All cases received 3D-CTA to observe the distribution and anastomosis of perforator vessel. Regular followed-up was made post-opera-tively. Results All patients had been followed-up for 6-18 months. Outpatient service combined with telephone follow-up was adopted. All flaps survived, and flap shape, colour and lustre, elasticity got good recover. At the last follow-up, thermann scale function assessment: 4 cases were excellent, 2 were good, and 1 was fair. Conclusion It is a feasible and effective method to repair massive soft tissue defects of shank and foot using differently combined flaps. Although the surgery can be risky, the method can effectively reduce the rate of limb disability, restore the limb func-tion and shorten the course of treatment.Preoperative 3D-CTA can get the vessel anatomical structure and diameter at donor and recipient sites, which will guide the operation program design and implementation so as to shorten the oper-ation time and improve the accuracy rate of vascular anastomosis.

Application of digital technique to assist in the reconstruction of thumb and fingers defect / 中华显微外科杂志

Objective To investigate the clinical significance of the reconstruction surgery using the toes to repair thumb and fingers defect with the help of the digital technology. Methods Between June, 2012 and May, 2017, 17 partial thumb and finger defects in 12 cases received 3D-CTA assisted finger reconstruction surgeries in us-ing the toe. Preoperative ipsilateral foot 3D-CTA were conducted and the 3D digital models were analyzed. It helped to know the parameters of the move direction and classification of the arteries and veins, etc.It was helpful for design-ing personalized surgical scheme that could match with the length of each finger defect and the defect area and shape in the recipient site of the specific case. Results All 17 toe-to-hand transplants in 12 cases survived. With 6-12 month's followed-up, the appearance of the reconstructed fingers was very closed to the normal fingers. The two-point discrimination was 6-10 mm. According to the upper extremity functional evaluation criteria issued by the Hand Surgery Society of the Chinese Medical Association, the results were rated as excellent in 9 digits, good in 6 digits, fair in 1 digit and poor in l digit. Conclusion The digital technology can help to formulate the operation scheme of personalized and accurate reconstruction of thumb and fingers before the operation.It was helpful to reduce the opera-tion risk and improve the survival rate of fingers reconstruction.It has very good practical and clinical significance.

The clinical value of 3D-CTA combined 3D-DSA in intracranial aneurysms / 中国医学装备

Objective: To research three-dimensional computed tomography angiography (3D-CTA) combined three-dimensional digital subtraction angiography (3D-DSA) in the diagnosis of intracranial aneurysms. Methods: 3D-CTA and 3D-DSA were performed in 27 cases with Highly suspected in patients with intracranial aneurysms, And compared with the final outcome of surgery. To evaluate 3D-CTA and 3D-DSA in the detection rate of aneurysms, three-dimensional shape and spatial relations ability to display. Research 3D-CTA combined 3D-DSA in the diagnosis of intracranial aneurysms. Results: Twenty-seven cases of suspected patients, 25 cases of surgical treatment of confirmed aneurysms, 28 aneurysms found. 3D-CTA and 3D-DSA rate of aneurysms was no significant difference. 3D-CTA of the aneurysm can be accurately detected clearly shows its three-dimensional shape and spatial relationship with the surrounding skull, 3D-DSA for aneurysm neck, the tumor and the aneurysm and parent artery relationship shows clear and accurate. Conclusion: Imaging of intracranial aneurysm diagnosis, 3D-CTA and 3D-DSA have their respective advantages, combined two methods can improve the detection rate of aneurysms. 3D-CTA combined 3D-DSA have support of design for operation.

Preliminary applications of the 3D-CTA assisted digital designing of the second toe transfers for the reconstruction of finger / 中华显微外科杂志

Objective To investigate the clinical significance of the 3D-CTA (three-dimensional computed tomography angiography)assisted design of finger reconstruction the second toe.Methods Between June 2010 and January 2013,five patients with finger defect received 3D-CTA assisted finger reconstruction surgeries using the second toe.Preoperative ipsilateral foot and hand 3D-CTAs were conducted and the 3D digital models were analyzed.The accurate positions and adjacent relations of vessels in both donor and recipient site were precisely marked and then the calibers of the vessels were measured.Four cases received thumb reconstructions and 1 case received little finger reconstruction.All of these surgeries were second-stage.According to Gu Yudong's classification of finger defect:second degree 2 cases,third degree 2 cases,five degree 1 case(little finger).Results With the help of 3D-CTA,five patients in this group had no vascular crisis,and all fingers survived successfully.With 4-12 months' follow-up,the algesthesia and thalposis of the reconstructed fingers gained good recoveries.The two-point discrimination was 5-10 mm.Tthe range of flexion of interphalangeal joint was 10 °-30 °.The range of flexion of the metacarpophalangeal joints was 35 °-80 °.And all patients restored walking and bearing functions with 3 months after surgeries.Conclusion The 3D-CTA reconstruction based digital model of ipsilateral foot and hand can objectively reflect the real situation of the vessels in both donor sites and recipient sites (exist of variations,routes and the calibers of the vessels),thus improve the success rate of surgery.

The Diagnostic Method and Importance of Intracranial Pseudoaneurysm Developed by Head trauma: Case report

Traumatic intracranial pseudoaneurysms are rare and it is easy to overlook the evaluation of intracranial vascular injury in head trauma patients in the emergency room. If the result of missing an intracranial aneurysm however is catastrophic. I describe a case of a patient with intracranial internal carotid artery (ICA) pseudoaneurysm after head trauma and stress the importance of obtaining a three-dimensional-computed tomogram angiography (3DCTA) in cases of patients with skull base fracture or eyeball pain. We report a case which a patient complained of severe headache and right eyeball pain after head trauma. 3D-CTA revealed carotid-cavernous fistula and pseudoaneurysm of the right ICA. After performing transfemoral carotid angiography (TFCA) and a balloon occlusion test, we carried out endovascular trapping of ICA and extracranial-intracranial (EC-IC) bypass surgery. Afterward, the patient was discharged without neurological deficit after two weeks. We recommended 3D-CTA in cases of head trauma when the patient has skull base fracture or sphenoid sinus fracture.

Role of Three-dimensional Computed Tomography Angiography in the Follow-up of Patients with Aneurysm Clips

OBJECTIVE: The purpose of this study is to assess the usefulness of three-dimensional computed tomography angiography (3D-CTA) as a postoperative follow-up examination after intracranial aneurysms have been clipped. METHODS: Between January 2002 and June 2005, 522 consecutive patients received treatment for intracranial aneurysms. A retrospective analysis of 310 patients with postoperative 3D-CTAs was performed to evaluate aneurysmal remnants and de novo aneurysms. This study was conducted in 271 patients with at least immediate and 6-month routine 3D-CTAs for postoperative clipped aneurysm and 39 patients with 3D-CTAs for clipped aneurysm before 2002 when there was no 3D-CTA in our hospital. RESULTS: Eight patients had abnormal CT angiographic findings. Aneurysm remnants were revealed in 4 patients and de novo aneurysms were discovered in 5 patients. Two patients were found at the postoperative 6-month 3D-CTA performed routinely. In 1 patient, the aneurysm was demonstrated on the way to the examination of syncope. In 2 patients, the author recommended 3D-CTA although there was no symptom because the patients had visited our institute long time ago (5.1, 4.5 years). Of the 8 patients, 2 remnants and 1 de novo aneurysm were treated by endovascular treatment. Three de novo aneurysms at the middle cerebral artery and 1 pericallosal artery aneurysm were treated by direct clipping because these aneurysms were not suitable for the endovascular treatment in point of anatomical configuration. One patient with both remnant and de novo aneurysm was treated conservatively. CONCLUSION: 3D-CTA is an available, non-invasive diagnostic tool for the postoperative follow-up examination of aneurysmal state in patients after clipping.

Usefulness of Angiographic Three-Dimensional Reconstruction of Spiral Computed Tomography Images for Postoperative Evaluation after Aneurysm Clipping with Titanium Clips

OBJECTIVE: The three-dimensional computed tomographic angiography(3D-CTA) images are not commonly used than the conventional digital subtraction angiography(DSA) as a postoperative examination to identify a remnant neck or whether the parent and branching arteries and the cerebral aneurysm are clipped together. We suggest that the neurosurgeons themselves can reconstruct 3D images using 3D reconstruction program in their personal computers and evaluate the aneurysm neck clipping state more precisely than DSA. METHODS: Both 3D-CTA and DSA images were obtained postoperatively on 40 patients with 45 cerebral aneurysms. 38 aneurysms were clipped by single clip, 6 by double clips, and 1 by triple clips. We compared 3D-CTA images, which are made by easy and noninvasive method of the new software to ascertain postoperatively the perfection of aneurysm neck clipping performed with titanium clips, with DSA. RESULT: Out of the total 45 cerebral aneurysms clipped with titanium clips, 3D-CTA clearly showed the state of the clipped necks and the parent and branching arteries of 44 aneurysms in 39 cases. There were three cases in which the remnant necks were found in 3D-CTA, but two of them were not identified in DSA. There was one patient who had cerebral aneurysms requiring 3 clips, resulting in a poor view of the remnant necks since the clips covered the necks. CONCLUSION: In case using one or two titanium clips for the aneurysmal clipping, 3D-CTA may be a reliable alternative method to DSA in the postoperative evaluation to define the cerebral aneurysm neck and the surrounding vessels after clipping.

3-Dimensional Computed Tomography Angiography in Early Operation for Poor Grade Aneurysms

OBJECTIVE: The authors studied the feasibility of 3-Dimensional computed tomographic angiography(3-D CTA) in early surgery for poor grade patients with aneurysmal subarachnoid hemorrhage(SAH), therefore intended to verify the eligibility of this diagnostic tool in these special clinical settings. METHODS: During the period between July 1997 and December 2000, we studied 31 patients diagnosed as aneurysmal SAH that were classified as the Hunt-Hess grade IV or V and Fisher group III or IV. As the conventional angiography could not be conducted because of the patients' poor clinical conditions, we carried out early surgery on the same day of SAH solely based on the 3-D CTA. We compared the 3-D CTA features with intraoperative findings. RESULTS: Total of 33 aneurysms were found in preoperative 3-D CTA and, of them, all 31 ruptured aneurysms and additional another two unruptured ones were also. Undetected three aneurysms were found in the operative field(2 cases) and postoperative digital subtraction angiography(1 case). The sensitivity of 3-D CTA was 94.7% and specificity was 100%. CONCLUSION: According to our results, 3-D CTA might be sufficient for early surgery of intracranial aneurysms in poor grade SAH patients in urgent conditions.

Practical Role of Three-Dimensional Computed Tomographic Angiography in Planning the Surgery for Intracranial Aneurysm

OBJECTIVES: The aim of this study is to evaluate the practical role of 3D-CTA in planning the surgery for intracranial aneurysm from a viewpoint of operator. METHODS: Since May 1997 to April 1998, a total of 65 patients who were suspected to have intracranial aneurysms were studied with 3D-CTA using a General Electric Hispeed Advantage helical scanner. Conventional intraarterial digital subtraction angiographies(IA-DSAs) were performed in all patients except four who were in urgent situation. With the images obtained from the 3D-CTA, we performed preoperative assessments for the targeted aneurysms and evaluated its usefulness for planning the aneurysm surgery. RESULTS: 3D-CTA revealed 69 intracranial aneurysms in 55 patients and the size of aneurysms detected were 2-17mm in diameter. The sensitivity of 3D-CTA(95.8%) which was based on the comparison with IA-DSA and supplemented by microsurgical finding was similar to that of IA-DSA(94.1%) and its specificity(81.8%) was lower than that of IA-DSA(100%). Time consuming for getting images from 3D-CTA was no more than 20 minutes and this rapidity was very useful in the emergent situation such as cases of large intracerebral hematoma or massive intraventricular hemorrhage. 3D-CTA proffered various perspective views including surgical view, which were valuable to estimate the degree of head rotation and the direction of clip insertion and to determine the permanent clip type preoperatively. Careful reviewing of 3D-CTA made it possible to minimize surgical procedures. We could omit routine rectus gyrus resection in twelve of 16 surgeries for A-com aneurysm and could operate sixteen of 19 ICA aneurysms successfully without routine extracranial carotid artery preparation. On the basis of 3D-CTA, we could select the appropriate surgical approach in cases of ophthalmic aneurysm or posterior circulation aneurysm. Moreover, in cases of bilateral multiple aneurysms, 3D-CTA was helpful for evaluating the possibility of visualizing contralateral aneurysm through unilateral approach. The extent of bone work could be determined preoperatively through reviewing the 3D-CTA images and possible rupture of MCA aneurysm during bone work could be avoidable. However, 3D-CTA had some limitations for the describing fine vascular architecture such as the teat of aneurysm, a clue for the ruptured aneurysm in multiple aneurysms and most of fine caliber vessels such as hypoplastic posterior communicating artery or anterior choroidal artery was missed on the 3D-CTA. 3D-CTA lacked description for the hemodynamics of cerebral circulation. CONCLUSIONS: Although the 3D-CTA is still insufficient to be the complete substitute for conventional intraarterial digital subtraction angiography, it may be excellent adjunctive tool in planning the surgery of intracranial aneurysm considering that understanding the exact relationship of aneurysm with surrounding structure is mandatory for minimizing the possible risk during surgery.

The Clinical Usefulness and the Value of 3D CT Angiography using Spiral CT in Patients with Cerebral Aneurysms

We evaluate the detection of cerebral aneurysms with 3-dimensional(3D) computed tomographic angiography(CTA) and compare the results with those of magnetic resonance angiography(MRA) and conventional cerebral angiography(CCA). Ten patients with 12 cerebral aneurysms were studied with spiral CT in conjuction with CCA and MRA. All aneurysms(3-20mm in diameter) were seen in CTA, MRA and CCA except 1 aneurysm(3mm in diameter) in MRA. CTA demonstrated neck, shape, direction of the aneurysm, and adjacent vascular and bony structures well. Of 12 aneurysms, 4 were seen equally with CCA and MRA, 4 were seen better with CCA owing to flow-related or motion artifact in MRA, and 4 were seen better with MRA. CTA was considered to be superior to CCA and MRA in demonstrating calcification and thrombosis in the aneurysm. 3D CTA with spiral CT is a rapid non-invasive method of visualizing the cerebral aneurysms and is comparable with MRA in demonstrating the aneurysms. We think 3D CTA can be a screening tool for use in the patients with suspected cerebral aneurysms and will be of a value in surgical planning for patients with complex cerebral aneurysms, in demonstrating the anatomy o the aneurysms and surrounding structures.