The use of arteriovenous anastomosis for venous drainage during Tamai zone I fingertip replantation.

PURPOSE: The purpose of this study was to evaluate outcomes for patients sustaining a distal fingertip amputation who underwent replantation witharteriovenous anastomosis for venous drainage over a one year period at our institution. This technique has been utilized when insufficient veins are identified in the amputated part for standard veno-venous anastomosis. METHODS: A retrospective study was performed on patients presenting from 2013 to 2014. Guillotine, crush, and avulsion/degloving injuries were included if they underwent fingertip (Tamai Zone I) replantation with arterial anastomosis for vascular inflow and arteriovenous anastomosis for venous drainage. The cases were further classified as Ishikawa subzone I and subzone II. RESULTS: Arteriovenous anastomosis for venous drainage during replantation was used in 45 digits in 35 patients. 41 of the 45 digits underwent successful replantation using this technique (91%). The mean active ROM in the DIP joint of the fingers and in the IP joint of thumbs was 65° and 57°, respectively. Sensory evaluation demonstrated a mean of 6.9 mm s2PD in digits where the digital nerves could be repaired. 11 replanted digits without nerve repair regained some sensory recovery with a mean of 9.6 mm s2PD. 91% of patients were highly satisfied with the appearance of the replanted digits based on Tamai criteria. CONCLUSIONS: Arteriovenous anastomosis for venous outflow should be considered during zone I fingertip replantation if sufficient veins are not identified in the amputated part. This technique may allow for more routine and successful distal replantation.

Innervation of nasal turbinate blood vessels in rhinitic and nonrhinitic children.

An immunohistochemical study of the nasal mucosa was done in pediatric patients attending an otorhinolaringology (ORL) clinic. The goal was a comparison between vascular innervation in patients with or without symptoms of chronic rhinitis. All patients had an indication for tonsillectomy prior to their inclusion in this study. Samples were obtained under general anesthesia at the time of programmed surgery and fixed in a paraformaldehyde-picric acid mixture. Cryostat sections were immunostained for the following neuronal markers: protein-gene product 9.5 (PGP), calcitonin gene- related peptide (CGRP), substance P (SP), and C-terminal peptide of neuropeptide Y (CPON). The following classes of vessels were identified: arteries, sinusoids, veins, and arteriovenous anastomoses (AVAs). As shown by immunostaining with the general neuronal marker PGP, each vessel type had a characteristic innervation pattern, differing in the amount of fibers and their distribution within the adventitial and muscle layers. Evaluation of PGP, CPON, and CGRP immunoreactivity patterns indicated that rhinitic arteries and AVAs displayed a richer innervation than did nonrhinitic blood vessels. Quantification of vascular PGP immunostaining confirmed the difference of vascular innervation between nonrhinitic and rhinitic patients. Fibers immunostained by CPON partially accounted for the rhinitic arterial hyperinnervation.

Arteriovenous anastomoses of the episcleral vasculature in the rabbit and rat eye.

PURPOSE: To obtain more information about the functional significance of arteriovenous anastomoses as regulatory elements, the authors investigated the topography and innervation of episcleral anastomoses in the rat and rabbit. MATERIALS AND METHODS: The topography of arteriovenous anastomoses in the limbal and episcleral vasculature of the rat and rabbit eye was studied by scanning electron microscopy of vascular resin casts. The perivascular distribution of the following neuropeptides was investigated by fluorescence immunohistochemistry: neuropeptide Y (NPY), vasoactive intestinal polypeptide (VIP), substance P (SP), and calcitonin gene-related peptide (CGRP). RESULTS: The episcleral arteriovenous anastomoses connect arterioles directly with the episcleral venous plexus which also drains the aqueous humor. The nerve fiber plexus around the episcleral arteriovenous anastomoses is far more dense than around arteriovenous connections at the limbal arcades. NPY-, VIP-, SP-, and CGRP-immunoreactive fibers concentrate at the arteriolar segment of the episcleral arteriovenous anastomoses and are reduced at the venular segment. Still, numerous VIP-IR fibers are on the venous side of the rabbit episcleral anastomoses. CONCLUSION: We conclude that the elaborated innervation of the episcleral anastomoses is a prerequisite for a subtle modulation of the blood flow and possibly of the aqueous humor outflow dynamics.

Hints of a functional connection between the neuropeptidergic innervation of arteriovenous anastomoses and the appearance of epithelioid cells in the rabbit ear.

Peripheral blood flow can be regulated by specialized vessel segments, the arteriovenous anastomoses. Their wall consists of a relatively thick layer of smooth muscle cells and so-called epithelioid cells. The epithelioid cell is a specialized myogenic cell phenotype expressing nitric oxide synthase. We studied the innervation of the different segments of arteriovenous anastomoses in the rabbit ear using antisera against neuropeptide Y, tyrosine hydroxylase, calcitonin gene-related peptide and substance P, as well as neuron-specific enolase, calbindin D and neurotubulin. The participation was especially examined of neuropeptidergic innervation and a possible morphological connection to the occurrence of epithelioid cells and a paracrine function. The NADPH diaphorase reaction and alpha-smooth muscle actin immunoelectron microscopy served to distinguish epithelioid cells from smooth muscle cells. Using conventional fluorescence microscopy and confocal laser scanning microscopy, we found the most dense innervation pattern of pan-neuronal markers (neurotubulin, neuron-specific enolase), tyrosine hydroxylase-immunoreactive nerve fibres and neuropeptidergic nerve fibres (neuropeptide Y, calcitonin gene-related peptide, substance P) around the intermediate segment in arteriovenous anastomoses, whereas the venous segment was barely marked. Single nerve fibres penetrated into the medial layer and reached the epithelioid cells. Using immunoelectron microscopy, we found intercellular contacts between epithelioid cells, but not the gap junction protein connexin 43. Here, we report for the first time a correlation of the innervation pattern with epithelioid cell type in arteriovenous anastomoses. Our findings suggest that epithelioid cells of the arteriovenous anastomoses are controlled by a dense network of neuropeptidergic nerve fibres in functional connection to their paracrine role as a nitric oxide producer.

Nitrergic innervation and nitrergic cells in arteriovenous anastomoses.

Nitrergic innervation and nitrergic epithelioid cells were studied in arteriovenous anastomoses of the tongue, ear, eye, and glomus organ of the finger in different species (rat, rabbit, dog, and man), by means of immunohistochemistry for nitric oxide synthase and enzyme histochemistry utilizing the catalytic activity of this enzyme (the NADPH-diaphorase reaction). Nitrergic perivascular fibers of the tongue were concentrated along the arterial tree and were maximal at the arteriovenous anastomoses in all species. Generally, fewer fibers were located around comparable segments of the episcleral eye vasculature. Only a few nitrergic fibers were found in the canine and rabbit ear, and in the glomus organ of the human finger; however, epithelioid cells in the tunica media of arteriovenous anastomoses of these organs were NADPH-diaphorase-positive and were moderately immunoreactive for nitric oxide synthase. In the epithelioid cells, the reaction product of the NADPH-diaphorase could also be demonstrated by transmission electron microscopy. The epithelioid cells were negative for the panneural and neuroendocrine marker PGP 9.5 confirming the myocytotic nature of these nitrergic cells. Thus, nitric oxide might play a role in mediating the vessel tone of arteriovenous anastomoses via nitrergic nerves or epithelioid cells.

The structure, innervation and location of arteriovenous anastomoses in the equine foot.

In the foot of the horse, arteriovenous anastomoses (AVAs) of epithelioid type occurred in the dermis of the coronary band, in the coronary and terminal papillae, in neurovascular bundles and at the entrance to and along the length of the dermal laminae. A particular feature of the epithelioid segment of AVAs in the horse, compared with that of other species, was the height and surface complexity of many of the endothelial cells. They extended into the lumen, forming undercut and tunnel-like areas which correlated with the characteristic surface marking of AVAs observed in vascular casts. The number of cell organelles, including the concentration of vesicles in the luminal cytoplasm, suggested cells with a high metabolic activity. The luminal surface possessed numerous microvilli and long cytoplasmic cell processes which appeared to surround material in the lumen. The innervation of AVAs was more dense than that of the arteries and consisted of adrenergic and peptidergic nerves. Noradrenaline- and neuropeptide Y-containing nerves were identified as the vasoconstrictor components of the nerve supply and occurred along arteries and formed dense plexuses around AVAs. Calcitonin gene-related peptide, substance P and vasoactive intestinal polypeptide are vasodilators and were present in single nerve fibres which accompanied arteries and AVAs along the length of the dermal laminae. In this study the distribution, density and innervation of AVAs in the equine foot are correlated with their proposed role in the development of acute laminitis. The release of vasoactive peptides from diseased organs remote from the foot may induce inappropriate prolonged dilatation of AVAs and thus contribute to the laminar ischaemia of acute laminitis.

Quantification of sympathetic vascular responses in skin by laser Doppler flowmetry.

An improved physiological test of focal sympathetic nervous function using a laser Doppler flowmeter is presented. The test evaluates rapid reflex changes in skin blood flow at the finger tip where there are abundant arteriovenous anastomoses with dense sympathetic innervation. Indirect body heating was employed in all subjects to induce central vasodilation and to obtain stable comparable finger tip blood flows prior to stimulus. The reflex vasoconstriction which occurs following inspiratory gasp and contralateral hand cold challenge was quantified and its reproducibility investigated on three separate occasions in 20 young subjects. The variability in responses both within and between young subjects was small. The test was applied to 10 diabetic patients with autonomic neuropathy and to 10 age-matched control subjects. Vasoconstrictor reflexes were significantly lower in the diabetic group (p less than 0.005) with responses lower than 2 SD from the mean for age-matched controls. In conclusion, the test provides an assessment of focal autonomic damage which can be applied to other regions of the body rich in arteriovenous anastomoses and may have application in clinical studies investigating autonomic activity.

Innervation of the arteriovenous anastomoses in the dog tongue.

Profiles of nerve plexuses in the arteriovenous anastomoses of the dog tongue were investigated by both transmission and scanning electron microscopy. Three-dimensional morphology of the vascular nerves was examined after removal of the connective tissue components by the HCl-hydrolysis method. Tight bending and a rich nerve supply were the most characteristic features of the anastomosing channels. The tunica media consisted of an outer circular layer of typical smooth-muscle cells and an inner region containing longitudinal plicae of ramified smooth-muscle cells. The tunica adventitia was exclusively occupied by nerve bundles; fibroblasts were poorly developed. Numerous nerve bundles of variable size were coiled around the anastomosing channels, and occasional bundles ran crosswise over the U-shaped bent vessels.

Innervation of arteriovenous anastomoses in the brood patch of the domestic fowl.

The innervation of blood vessels in the brood patch (thoracic skin) of the domestic fowl was studied by use of the catecholamine fluorescence technique, acetylcholinesterase staining, and the immunoperoxidase technique for demonstration of vasoactive intestinal polypeptide (VIP). Large arteries and veins were sparsely innervated, whereas arteriovenous anastomoses (AVAs) were densely innervated by adrenergic, acetylcholinesterase-positive, and VIP-immunoreactive nerve fibres. The rich supply of different vasomotor nerves to AVAs emphasizes the importance of these vascular shunts in regulating blood flow and, in turn, the transport of heat to the brood patch. Furthermore, the presence of VIP-immunoreactive nerve fibres in the vasculature of the brood patch suggests that VIP might be the mediator of the previously reported cold-induced vasodilatation.

Innervation of arteriovenous anastomoses in the sheep tongue: immunocytochemical evidence for coexistence of neural transmitters.

In this study structural and immunocytochemical evidence has shown that arterial vessels, particularly AVAs, are associated with nerves containing peptidergic vasodilators, viz. VIP, CGRP and SP. The presence of VIP-like immunoreactivity in both P-type and C-type nerves is evidence of the coexistence of VIP and acetylcholine in cholinergic nerves and suggests the action of VIP in maintaining the opening of AVAs in heat stress conditions. The evidence for the co-existence of CGRP and SP is more direct as immunoreactivity for both peptides has been demonstrated in serial sections of the same nerve terminal. Although SP is a potent vasodilator there is little evidence of its role in thermoregulation; however it may be involved in a local axon reflex and cause antidromic vasodilatation of local vessels particularly AVAs.

Tentative identification of arterial baroreceptors associated with arteriovenous anastomoses.

Nerve endings of the trigeminal nerve were examined in the lip, nostril, upper jaw and supraorbital skin of cat by the horseradish peroxidase (HRP) tracing method. Wheatgerm agglutinin-HRP (WGA-HRP) as injected into the spinal trigeminal nucleus was transported transganglionically to nerve endings. The present study deals with presumptive baroreceptive nerve endings found on arteriovenous anastomoses and on some other large arteries. By light microscopy HRP-labeled, complexly arborized nerve endings were found on the walls of arteries located deep in the subcutaneous tissue of the lip and nostril. These arteries were identified in serial sections to be an arterial segment of an arteriovenous anastomosis. By electron microscopy characteristic nerve endings were located in the adventitia and partly extended into the adjacent connective tissue of the arterial wall. These terminals had no connective tissue capsule. Axon terminals were somewhat enlarged (1-2 microns in diameter) and extended through bundles of collagen fibrils. The terminals contained an abundance of mitochondria and some vesicles. Axon terminals were typically covered by thin Schwann cell processes, but parts of the axolemma were sometimes devoid of such Schwann cell coverings, being invested only by basal laminae. Cell bodies of Schwann cells were located apart from axons. These light and electron microscopic features of the endings resembled those of other well-defined baroreceptors reported in the carotid sinus, aortic arch and endocardium, as well as of Ruffini terminals and Golgi tendon organs, suggesting that they would be baroreceptors of arteriovenous anastomosis. In addition HRP-labeled single nerve fibers with varicosities were found in the walls of some large arteries in the facial skin. By electron microscopy, such a HRP-positive nerve fiber contained some mitochondria and vesicles in varicosities and coursed with a bundle of HRP-negative fine fibers in the adventitia of arteries. These HRP-labeled single fibers were considered to be sensory derived from trigeminal nerves.

Autonomic innervation of the arteriovenous anastomoses in the dog tongue. A histochemical and ultrastructural study.

The innervation of the arteriovenous anastomoses in the dog tongue has been investigated. At the light-microscopic level, the vessels were found to be densely supplied with adrenergic and AChE-positive nerve plexuses and less densely with the quinacrine-binding nerve plexus. At the electron-microscopic level, at least two apparently different types of axon profiles were identified: Small vesicle-containing axons, characterized by many small granular vesicles, variable numbers of small clear vesicles and large granular vesicles. Storage of endogenous amines and uptake of exogenous amines into most small granular vesicles and many large granular vesicles was demonstrated. These axons stained only lightly with reaction products for AChE activity and thus seemed to be adrenergic in nature. Some axons contained numerous large granular vesicles, whose cores occasionally stained with uranyl ions; this suggests a co-localization of ATP or peptides as neurotransmitters. Small granular vesicle-free axons, containing small clear vesicles and large granular vesicles in variable ratio. Most cores of these large granular vesicles were heavily stained with uranyl ions. No storage or uptake of amine into the synaptic vesicles was detected. Some axons appeared to be typically cholinergic, some, typically non-adrenergic, non-cholinergic, and the rest, intermediate between the two. All axons stained heavily with reaction products for AChE activity, suggesting their cholinergic nature.

Responsiveness of microcirculation and local cold vasodilation to capsaicin in the intact and chronically denervated canine tongue.

Lingual blood flow and its distribution were determined at rest and in response to local cooling of the tongue (32 degrees C) in 6 anaesthetized, paralyzed and artificially ventilated dogs before and after two intraarterial (i.a.) injections of capsaicin (2.5 mg) at an interval of about 40 min. In 3 dogs, the same protocol was performed after degeneration of the chorda-lingual and glossopharyngeal nerves due to prior transection. In general the first i.a. injection of capsaicin resulted in a marked and the second injection in a smaller decrease of lingual blood flow. Local cooling of the tongue induced significant increases in lingual blood flow before as well as after capsaicin treatment, regardless of whether sensory innervation was intact or degenerated. In both the untreated and capsaicin treated dogs the increase in lingual blood flow during local cooling of the tongue was solely due to an increase in blood flow through the arteriovenous anastomoses, while blood flow through the capillaries of the mucosa and muscles even decreased. The findings suggest that capsaicin-induced vasoconstriction of the tongue vessels is due to a direct effect on vascular receptors. It is further suggested that cold vasodilatation of the canine tongue is not mediated by axon collaterals releasing substance P. Direct thermal effects on the intramural ganglia and the postganglionic vasomotor efferents innervating the AVAs, or on AVAs basal tone itself are suggested as the underlying mechanism.

The effect of sympathetic innervation on canine muscle and skin blood flow.

Two microsphere techniques were used to measure skin and muscle capillary blood flow, plus blood flow through arteriovenous anastomoses (AVAs), before and after unilateral lumbar sympathectomy in 12 anesthetized dogs. Sympathectomy did not alter capillary flow to tibial muscle, thigh, or lower leg skin, whereas paw skin capillary flow decreased, from 28 to 13 mL/min/100 g. However, total extremity blood flow increased after sympathectomy, because of the rate of AVA flow, which increased from 7 to 30 mL/min. Transient nerve stimulation of the cut distal end of the lumbar sympathetic chain immediately and reversibly decreased the AVA flow rate, from 30 to 10 mL/min. The rate of total hind-limb capillary flow also decreased during nerve stimulation, from 86 to 46 mL/min. The only significant effect of sympathectomy in anesthetized dogs was to redistribute distal hind-limb capillary blood flow to AVAs, which are anatomically located in this region. In contrast to capillaries, AVAs have little intrinsic myogenic tone and are highly dependent on adrenergic innervation.

The role of adrenergic mechanisms in thermoregulatory control of blood flow through capillaries and arteriovenous anastomoses in the sheep hind limb.

The possible role of adrenergic mechanisms in thermoregulatory changes in the partition of femoral blood flow between nutrient (capillary) and non-nutrient (arteriovenous anastomoses, AVA) circuits in the hind limb of conscious sheep has been investigated employing radioactive microsphere and electromagnetic blood flow measurement techniques. Constriction of AVAs, normally induced by spinal cooling, could be inhibited by phentolamine, whereas dilatation of AVAs, normally induced by spinal heating, could be inhibited by noradrenaline or methoxamine. AVA constriction could be induced by noradrenaline or methoxamine, or dilatation by phentolamine. Isoprenaline had a small dilator and propranolol a small constrictor effect on AVAs. It is concluded that adrenergic pathways involving predominantly alpha-receptors play a role in thermoregulatory changes in skin blood flow (through AVAs) elicited by manipulation of CNS temperature; under these conditions, beta-receptors do not play any role, although manipulation of their activity will influence AVAs under non-thermoregulatory conditions. Capillary blood flows in skin, bone and fat were sensitive, at different ambient temperatures and to varying degrees, to some alpha- and beta-adrenergic agents.

Innervation of arteriovenous anastomoses in the web of the foot of the domestic duck, Anas platyrhynchos: structural evidence for the presence of non-adrenergic non-cholinergic nerves.

An analysis of the innervation of arteriovenous anastomoses in the web of the foot of the Pekin Duck (Anas platyrhynchos) was compared with the innervation of the right atrium of the duck heart using histochemical, ultrastructural and morphometric techniques, before and after 6OHDA. The presence of intense catecholamine fluorescence and nerve terminals containing typical noradrenergic small dense-cored vesicles, together with the absence of fluorescence and degeneration of noradrenergic terminals after 6OHDA, indicated the presence of a dense adrenergic innervation at the periphery of the anastomoses. Ultrastructural and histochemical data gave support to the presence of a cholinergic innervation. There was evidence that arteriovenous anastomoses were innervated by non-adrenergic, non-cholinergic nerves, viz. after 6OHDA, the mean diameter, mean percentage and mean density of granular vesicles in axon profiles associated with anastomoses (107 . 25 nm, 22 . 34% and 12 . 73 vesicles micron-2, respectively) were significantly higher (P less than 0 . 001) than values in the atrium (87 . 13 nm, 9 . 92% and 5 . 51 vesicles micron-2, respectively) and axons associated with anastomoses contained large granular vesicles ranging up to 210 nm in diameter. This non-adrenergic non-cholinergic innervation may represent the non-adrenergic non-cholinergic vasodilatory nerves shown by pharmacological methods to be present in the foot of the Pekin Duck.

Vasomotion in chicken foot: dual innervation of arteriovenous anastomoses.

Blood exits the foot of the domestic chicken via two major venous routes: a counter-current network surrounding the major incoming artery and a large collateral vein. Between these two routes are numerous large collateral vein. Between these two routes are numerous anastomotic veins. Both venous routes drain capillaries and arteriovenous anastomoses (AVAs). Blood flow through the foot was measured on unanesthetized hens. Flow varies with ambient temperature: 0.2 ml/min at 5 degrees C, 2.2 ml/min at thermoneutrality, and 5.4 ml/min at 36 degrees C; the AVAs contribute 8, 26, and 63% to this flow, respectively. Flow through capillaries is reduced by alpha-adrenergic agonists and is increased by beta-adrenergic agonists. Blocking nerve conduction to the foot at thermoneutrality releases alpha-adrenergic tone and increase AVA flow. Faradic stimulation of foot nerves after adrenergic blockage increases AVA flow, but not capillary flow, suggesting active vasodilation of the AVAs. Such AVA vasodilation normally occurs during body heating, since AVA flow decreases after denervation. Dopaminergic or beta-adrenergic nerves are not involved in active vasodilatation, however, purinergic nerves may play a role. Thus AVAs have a functional dual innervation.