Search Results (137)

Background and Objectives: Extramammary Paget’s Disease (EMPD) of the perineal region is a rare intraepidermal adenocarcinoma requiring wide excision, resulting in extensive defects that are challenging to reconstruct while preserving contour and function. This descriptive case series evaluated a reconstructive selection strategy using pedicled superficial circumflex iliac artery perforator (SCIP) flaps and pedicled anterolateral thigh (ALT) flaps for perineal defects following wide excision of EMPD. Materials and Methods: This retrospective case series reviewed patients with perineal EMPD who underwent wide excision followed by reconstruction using pedicled SCIP flaps or pedicled ALT flaps. Patient demographic and lesion characteristics, operative and flap characteristics, post-reconstruction complications, oncologic outcomes, and satisfaction were analyzed. Results: 15 patients (mean age 63 years, SD 7.3) were included in this case series. Ten patients underwent reconstruction using pedicled SCIP flaps (mean 106 cm², SD 23.3), and five patients with pedicled ALT flaps (mean 245.2 cm², SD 41.2). All flaps survived, but one patient developed limited partial necrosis managed with secondary healing. During a mean follow-up of 17.7 months (SD 1.3), one patient (6.7%) developed recurrence and eventually distant metastasis resulting in death. Among the 14 surviving patients, 13 (92.9%) reported overall satisfaction with cosmetic and functional outcomes assessed using a non-validated ordinal scale. Conclusions: Pedicled SCIP and ALT flap reconstruction provides reliable, well-vascularized tissue coverage for perineal EMPD defects and achieves generally favorable short-term outcomes. The choice between flap types should be tailored to the defect size, location, and patient characteristics. Full article

Background/Objectives: Ischemic injury resulting from the blockage of the left coronary artery or its terminal left anterior descending and circumflex branches is associated with relatively high rates of morbidity and mortality. Variations in left coronary artery size and the number of terminal branches may in part influence the development of such blockages due to altered intraluminal fluid dynamics, while also potentially complicating medical imaging interpretation or preoperative planning for interventions of coronary circulation. While left coronary artery morphology has been extensively reported on, the results reveal substantial geographical variability, with the Eastern United States being largely underrepresented. Methods: We aimed to establish baseline measurements of left coronary artery length and width and the prevalence of variable branching patterns by examining 101 cadaveric hearts from adult, whole-body donors (59 F, 42 M) that were ethically willed to the State of Virginia. Results: The most common terminal branching pattern was left coronary artery bifurcation (n = 54), followed by trifurcation (n = 45), tetrafurcation (n = 1), and aberrant circumflex artery origin, with the left coronary artery traveling in the anterior interventricular sulcus without branching (n = 1). Compared to females, the left coronary artery of males was significantly longer ($\overline{\mathrm{x}}$ = 14.87 mm ± 5.73 mm vs. $\overline{\mathrm{x}}$ = 12.64 mm ± 4.79; p = 0.04) and wider ($\overline{\mathrm{x}}$ = 6.31 mm ± 1.10 mm vs. $\overline{\mathrm{x}}$ = 5.54 mm ± 0.90 mm; p < 0.01), regardless of terminal branching pattern. Conclusions: These results can support the interpretation of coronary angiograms and the preoperative planning of surgical interventions involving coronary vasculature. Full article

Background/Objectives: Computer-aided surgical planning (CASP) technologies, including virtual surgical planning (VSP), 3D printed cutting guides, and patient-specific implants, have been increasingly applied to deep circumflex iliac artery (DCIA) free flap reconstruction of maxillofacial defects. Despite growing adoption, no systematic review has specifically evaluated their accuracy and clinical outcomes. This study aimed to comprehensively assess the impact of CASP on reconstruction accuracy, operative efficiency, flap survival, and implant rehabilitation in DCIA flap surgery. Methods: A systematic search of PubMed, Web of Science, and Google Scholar was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Studies reporting CASP-assisted DCIA free flap reconstruction with three or more patients were included. Methodological quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) checklist and the Cochrane Risk of Bias 2.0 tool for the randomized controlled trial (RCT). Results: Thirty studies (1 RCT, 13 comparative, and 16 non-comparative) involving 844 patients were included. VSP with 3D-printed cutting guides was the most frequently used technology (n = 22). Mean linear deviations between planned and actual outcomes ranged from 0.40 to 4.4 mm, with most studies reporting 0.7–2.7 mm. The sole RCT demonstrated significantly better accuracy (1.3 vs. 5.5 mm, p < 0.001) and shorter reconstruction time (16 vs. 39 min, p < 0.001) with CASP. Flap survival ranged from 90% to 100%. Conclusions: CASP technologies, particularly VSP with 3D-printed cutting guides, appear to improve the accuracy and predictability of DCIA flap reconstruction. However, the evidence base is predominantly retrospective and heterogeneous; prospective multicenter studies with standardized outcome measures are needed before definitive clinical guidelines can be established. Full article

Background: Kounis syndrome is an acute coronary syndrome triggered by hypersensitivity reactions, which may result in coronary vasospasm, thrombosis, or stent-related complications. Case Summary: A 64-year-old male smoker with dyslipidemia and recently diagnosed urothelial carcinoma presented with exertional angina and underwent coronary angiography. Percutaneous coronary intervention was performed for a critical proximal–mid left anterior descending artery lesion using a drug-eluting stent. Immediately after stent deployment, the patient developed diffuse multivessel coronary vasospasm involving the left main stem, left anterior descending, and left circumflex arteries, accompanied by slow-flow/no-reflow phenomena and subsequent acute in-stent thrombosis. The clinical course rapidly progressed to ventricular arrhythmias and cardiogenic collapse. Despite transient return of spontaneous circulation after cardiopulmonary resuscitation, the patient developed fatal asystole during a repeat angiographic attempt. No cutaneous or respiratory allergic manifestations were observed. The abrupt onset of diffuse coronary dysfunction immediately following contrast exposure was suggestive of suspected Kounis syndrome, although mechanical causes and chemotherapy-related vasospasm could not be entirely excluded. Conclusions: Diffuse coronary vasospasm with multivessel dysfunction occurring abruptly after contrast exposure should raise suspicion for Kounis syndrome, even in the absence of overt allergic manifestations. Early recognition is essential to avoid misattribution to procedural complications and may be particularly important in patients with malignancy undergoing invasive coronary procedures. Full article

Giant coronary artery aneurysms, defined as those with a diameter exceeding 8 mm or a four-fold increase relative to the reference vessel segment, are incredibly rare, with an estimated prevalence of approximately 0.02% in the general population. We present computed tomography angiography images of a thrombotic occlusion of a giant right coronary artery (RCA) aneurysm. An 80-year-old Caucasian man with chronic coronary artery disease, who had undergone percutaneous coronary intervention of the middle segment of the left circumflex artery (LCx) with drug-eluting stent implantation, was referred to the computed tomography department for coronary computed tomography angiography (CCTA) due to difficulty visualizing RCA during invasive coronary angiography. In CCTA, a giant aneurysm in the proximal segment of the RCA, with a massive thrombus, communicating with the typical origin of the RCA from the right aortic bulb sinus, then extending into the occluded part of the proximal segment of the RCA, was visualised. The maximum long dimension of the RCA aneurysm was 5.3 cm, and the maximum short dimension of the RCA aneurysm was 4.4 cm. The maximum thrombus thickness in the RCA aneurysm was 2.2 cm. The middle and distal segments of the RCA, presumably filled with collateral circulation, have significantly weaker contrast, and contain numerous predominantly calcified atherosclerotic plaques. In summary, the presented CCTA images confirm the clinical importance of this modality in diagnosing coronary artery aneurysms, even in situations where the results of invasive coronary angiography remain equivocal. Due to higher spatial resolution, the ability to perform image reconstruction in multiple planes, the ability to detect thrombus, and the ability to assess the vessel wall and extracoronary structures, CCTA not only enables the detection of coronary artery aneurysms but also enables risk prediction, thus enabling the planning of a more optimal treatment strategy. Full article

Traumatic thumb loss causes severe functional impairment, as the thumb provides approximately 40% of total hand function. Toe-to-thumb transfer remains the gold standard for thumb reconstruction, yet donor site morbidity represents a significant functional and aesthetic limitation. A total thumb reconstruction using a “trimmed” right great toe transfer, combined with immediate donor site reconstruction using a free SCIP (superficial circumflex iliac perforator) flap and iliac crest bone graft. The flap was designed as a tubular skin island to create a neo-hallux with optimal contour and volume, minimizing visible scarring and avoiding microcirculatory compression. The patient, a 33-year-old man with post-traumatic thumb avulsion, underwent delayed reconstruction three months after injury. The postoperative course was uneventful, with no vascular or wound complications. At 12 months, he resumed full ambulation and manual activities, including motorcycle driving and work tasks. Baropodometric analysis demonstrated symmetric load distribution and gait dynamics. Thumb opposition was satisfactory (Kapandji score: seven); the patient rated the aesthetic results as excellent. This case demonstrates that SCIP flap reconstruction with iliac crest bone graft enables complete functional and aesthetic restoration of the great toe donor site after total toe transfer. Compared to previous techniques using cross-flaps, skin grafts, or peroneal flaps, this approach minimizes morbidity, optimizes cosmetic outcomes, and preserves gait. Although representing a single case, this constitutes the first documented instance of total hallux reconstruction following toe-to-thumb transfer, emphasizing the importance of the foot as a functional and aesthetic unit and the need for donor-site preservation in microsurgical reconstructive planning. Full article

Background and Clinical Significance: Revascularization of the circumflex territory remains technically challenging because of its anatomical position and the frequent need for distal branch grafting. Case presentation: We report the case of a 76-year-old man in whom the proximal circumflex trunk was used as the target for an in situ right internal thoracic artery routed through the transverse sinus during combined coronary and ascending aortic surgery. This approach allowed antegrade perfusion of the circumflex territory while avoiding multiple distal anastomoses. In this selected anatomical setting, the technique proved feasible and was associated with excellent intraoperative flow and 1-year radiological patency. Conclusions: Direct grafting of the circumflex trunk is not a new concept, but this case revisits it using a contemporary total arterial revascularization strategy. This approach may represent a useful adjunctive option in carefully selected patients with favorable circumflex anatomy. Full article

Background and Objectives: Fragmented anatomical, imaging, and surgical accounts of the gracilis muscle hinder reproducible reporting and operative planning. We aimed to integrate prior systems into an Integrated Gracilis Framework (IGF)—an integrative synthesis, not a new classification—that harmonizes terminology, defines imaging correlates/pitfalls, and links morphology to surgical decisions. Methods: Integrative narrative review (January 1900–October 2025) of PubMed/MEDLINE, Scopus, and Web of Science covering vascularization (pedicles, perforators), innervation (motor points/segments), imaging (ultrasound, MRI, MR neurography, CTA/MRA), and clinical applications (facial reanimation, elbow flexion, perineal and breast reconstruction). Two reviewers screened/extracted with consensus adjudication. Searches were restricted to English or records with reliable English-language summaries. Results: IGF consolidates morphological variants, motor-point/segmental innervation, and pedicle/perforator patterns with imaging correlates and common pitfalls. It provides a crosswalk mapping historical systems to IGF and a proposed preoperative workflow (anatomy → imaging → harvest → neurotization) for structured planning and reporting (proposed framework; not prospectively validated). We summarize considerations for free/functional gracilis in facial reanimation and elbow-flexion, and for pedicled/free myocutaneous or perforator flaps in perineal and breast reconstruction. Conclusions: IGF offers a standardized language and decision scaffold to improve study comparability and transparency in operative reporting; as a nonvalidated synthesis, it requires systematic validation through cadaver–imaging correlation and prospective surgical cohorts. Full article

Background: The fat attenuation index (FAI) derived from coronary computed tomography angiography (CTA) is an emerging imaging biomarker of perivascular inflammation. Coronary flow reserve (CFR), assessed by phase-contrast (PC) cine cardiac magnetic resonance (CMR) of the coronary sinus, reflects coronary microvascular function. Although FAI has been linked to adverse outcomes in coronary artery disease (CAD), its relationship with CFR across different CAD stages is not well defined. Methods: We retrospectively evaluated 241 patients (mean age 73.4 ± 10.8 years; 149 men [61.8%]) who underwent both coronary CTA and CMR (122 with known CAD and 119 with suspected CAD). FAI was measured in the proximal left anterior descending (LAD), left circumflex (LCX), and right coronary (RCA) arteries. Impaired CFR was defined as <2.0. Univariable and multivariable logistic regression analyses were performed to identify factors associated with impaired CFR. Results: Impaired CFR was observed in 38 of 122 patients (31.1%) with known CAD and 26 of 119 (21.8%) with suspected CAD. Higher LAD-FAI was associated with impaired CFR in both groups: OR 1.06 (95% CI 1.01–1.11; p = 0.018) in known CAD and OR 1.08 (95% CI 1.02–1.15; p = 0.017) in suspected CAD. Correlation analysis also demonstrated an inverse relationship between LAD-FAI and CFR (p < 0.001), and the strength of association was comparable between the two groups. Conclusions: LAD-FAI was associated with impaired CFR in both suspected and known CAD, with comparable strength of association across the two groups. These findings indicate that perivascular inflammation, reflected by FAI, may relate to coronary microvascular dysfunction in different stages of CAD. Full article

Objectives: To assess the diagnostic accuracy of a fully automated deep learning (DL) model for coronary artery segmentation and calcification detection on non-contrast, non-gated CT scans. Methods: A two-stage 3D segmentation pipeline was developed using 42 non-contrast and 27 contrast-enhanced CT scans to identify coronary artery calcifications in the right coronary artery (RCA), left anterior descending artery (LAD), and left circumflex artery (LCX). The model was trained with anatomically refined labels and region-based optimisation to improve structural coherence. Model outputs were visually assessed in a separate cohort of 100 scans by two independent, experienced observers. Segmentation and detection performance were evaluated against manually annotated reference standards using a binary analysis in 473 internal and external scans. Volumetric measurements of calcifications were compared with baseline severity gradings derived from radiologist reports. Results: Most model outputs were rated as excellent in the visual assessment, with good agreement between the outputs and manual reference standards for coronary artery segmentation (κ 0.68 to 0.81) and calcification detection (κ 0.79 to 0.85). The model accurately detected the presence of calcifications in the RCA (κ = 0.82, p < 0.001), LAD (κ = 0.93, p < 0.001), and LCX (κ = 0.82, p < 0.001). The diagnostic accuracy metrics of the model for calcification detection were: sensitivity, 95%; specificity, 98%; positive predictive value, 99%; and negative predictive value, 88%. The volume of calcification yielded by the model correlated with radiologist-reported disease severity, with regression coefficients of 28.3 for RCA, 28.7 for LAD, and 77.5 for LCX. Conclusions: The developed DL model segmented the coronary arteries, detected the presence of calcifications, and predicted disease severity with high accuracy. Full article

This pilot hypothesis-generating study evaluated whether lipid-related biomarkers (Lp(a), ApoB, and oxLDL), endothelial injury markers (endocan, vimentin), and extracellular matrix glycoproteins (TSP-1, TSP-2) reflect the severity of coronary artery disease (CAD) in patients with stable angina pectoris. 93 patients underwent invasive coronary angiography/coronary CT angiography. CAD severity was evaluated using Gensini, SIS, SSS, and CAD-RADS scores. CAD was confirmed in 76.3% (n = 71). OxLDL correlated with Gensini (r = 0.455; p = 0.006), atherosclerotic segments (r = 0.469; p = 0.005), arteries (r = 0.479; p = 0.004), revascularization indication (r = 0.318; p = 0.003), circumflex artery stenosis (r = 0.323; p = 0.005). OxLDL also correlated with vimentin (r = 0.459; p < 0.001). Vimentin correlated with Gensini (r = 0.480; p = 0.005), SIS (r = 0.349; p = 0.003), SSS (r = 0.320; p = 0.008), CAD-RADS (r = 0.331; p = 0.005), atherosclerotic segments (r = 0.515; p = 0.003), arteries (r = 0.384; p = 0.030), revascularization indication (r = 0.324; p = 0.003). Endocan, TSP-1, and TSP-2 showed no significant associations. These exploratory findings suggest that oxLDL and vimentin may be associated with CAD severity; however, confirmation in larger, prospective cohorts is required. Full article

Objective: To assess the effectiveness of a fixed contrast injection protocol—75 mL of contrast followed by 40 mL saline at 5 mL/s with an injection duration of 23 s—in achieving diagnostic enhancement in coronary CT angiography (CCTA) using 64-slice detector CT scanner. Materials and Methods: 456 consecutive patients with suspected coronary disease who underwent CCTA on a 64-slice detector CT scanner between January 2023 and December 2024 and were retrospectively enrolled. Each patient received 75 mL of contrast medium followed by 40 mL of saline at a flow rate of 5 mL/s, with a total injection duration of 23 s. Two radiologists, blinded to patient information, independently measured the contrast enhancement (HU) values in the coronary segments, ascending and descending aorta, and left ventricle. Attenuation levels ≥250 HU were considered diagnostic. Patients were grouped by body weight into two categories: Group 1 (≤75 kg) and Group 2 (>75 kg). The independent t-test and Mann–Whitney U test were used to compare HU values in each vessel between the two groups, while the Chi-square test was applied to compare enhancement success rates (HU ≥ 250) between the groups per vessel. Results: A total of 281 patients (mean age: 51.88 years ± 11.15 [SD]; 167 male, 114 female), were included. Statistically significant differences in the HU enhancement measurements were found between groups (p < 0.001–0.007). However, all segments showed mean and median HU values above 250 HU. Enhancement success rates were significantly higher in Group 1 (p = 0.005–0.04), except in the ascending aorta, descending aorta, left main coronary artery, middle right coronary, distal right coronary artery, and middle left circumflex artery, where the rates were statistically comparable between the groups (p = 0.054–0.61). Conclusions: A fixed contrast protocol (75 mL of contrast medium followed by 40 mL of saline at a 5 mL/s flow rate with a total injection duration of 23 s) appears to be feasible for achieving diagnostic contrast enhancement in CCTA using a 64-slice multidetector CT scanner. This protocol may offer a simplified alternative to individualized, weight-based contrast dosing strategies. Full article

Total Coronary Revascularization via left Anterior Thoracotomy (TCRAT) represents a modern evolution of sternum-sparing, on-pump multivessel coronary artery bypass grafting. In this review, we will summarize the historical development, detail the surgical principles, and provide a comprehensive overview of the clinical outcomes of TCRAT. The technique combines cardiopulmonary bypass using peripheral arterial as well as venous cannulation and cardioplegic cardiac arrest using transthoracic aortic cross-clamping with surgical access through a left anterior minithoracotomy. By applying special slinging and rotational maneuvers, both a stable exposition of all coronary territories—in particular those of the right and the circumflex coronary artery—and a quiet, bloodless operating field enable complete anatomical revascularization and complex coronary surgery procedures, including all variations in multiarterial grafting in unselected patients. Data from all published clinical series were integrated, and a weighted analysis of a total of 2282 patients was performed. TCRAT proved to be very effective with regard to complete anatomical revascularization and modern grafting strategies, and it showed excellent perioperative safety in an all-comers population. Both the 30-day mortality and perioperative stroke incidence were distinctly below 1.0%. Data from mid-term follow-up, although rare so far, are promising and compare well to those of the important RCTs. The TCRAT approach eliminates sternal complications completely and accelerates recovery. As an on-pump arrested-heart surgery, TCRAT inherently permits the combination of minimally invasive multivessel CABG with a variety of other cardiac operations, mainly the combination with valve procedures. The integration of robotic and endoscopic assistance represents the next evolutionary step. With its reproducibility and broad applicability, TCRAT holds strong potential to become a standard routine technique in the field of minimally invasive cardiac surgery. Full article

Background/Objectives: Extended pelvic lymph node dissection (ePLND) is the standard approach for staging intermediate- and high-risk prostate cancer (PCa), but the optimal extent of the procedure is still being debated due to the need to balance staging benefits with postoperative complications. This study aimed to assess whether the deep circumflex iliac vein, a consistent anatomical venous landmark, can guide a more selective dissection template that maintains staging accuracy while reducing morbidity. Methods: We conducted a retrospective analysis of 32 patients with intermediate- or high-risk PCa and histologically confirmed nodal metastases who underwent minimally invasive extraperitoneal radical prostatectomy with ePLND between 2018 and 2024. The lymph nodes located above (supra-venous) and below (infra-venous) the landmark vein were dissected separately and analysed histologically. Postoperative lymphoceles and related complications were recorded. Results: No metastatic lymph nodes were found in the subvenous region across all patients. All positive nodes were located cranially to the landmark, primarily in the obturator, internal iliac and proximal external iliac regions. Lymphoceles occurred in all patients, 62.5% of whom were symptomatic, 43.8% of whom had a fever, and 18.8% of whom were septic and required drainage. Four patients underwent laparoscopic reintervention for recurrent lymphoceles. Conclusions: The absence of metastatic involvement in the subvenous region suggests it is an oncologically low-yield zone. A refined dissection template omitting this area, guided by a reproducible venous landmark, may lower complication rates without compromising staging accuracy. Prospective validation is warranted before clinical adoption. Full article

Background: Coronary disease (CAD) is a multifactorial complex pathology characterized by excessive inflammatory activation and oxidative stress. Amino acids are among the potential biomarkers for cardiovascular pathology. The analysis aimed to investigate the possible relationship between proteomic profiling and coronary artery disease risk as novel markers of CAD. Methods: Patients with similar demographic and clinical profiles, including the prevalence of comorbidities such as arterial hypertension, dyslipidemia, and diabetes mellitus, were divided into two groups based on the results of their coronary angiograms. Serum amino acid levels were measured using liquid chromatography–tandem mass spectrometry. Results: Patients with significant coronary atherosclerosis confirmed in coronary angiograms were characterized by higher levels of circulating cystine, threonine, methionine, and proline. The number of involved coronary arteries in atherosclerotic processes revealed a correlation with circulating levels of threonine, methionine, and proline, not cystine. The multivariable logistic regression analysis for any significant coronary artery disease prediction revealed higher values of circulating threonine as a possible risk factor. Thereafter, a subanalysis was conducted to examine the relationship between amino acid levels and atherosclerotic risk in specific coronary arteries. The multivariate analysis revealed cystine and proline as potential risk factors for atherosclerosis of the left descending artery (LAD). Higher values of threonine were identified as a possible risk factor for atherosclerotic plaque location in the circumflex artery in multivariate regression analysis. Proline circulating levels were found to be prognostic for right coronary artery disease. Conclusions: Elevated circulating levels of amino acids, including cystine, threonine, methionine, and proline, were observed in patients with significant coronary artery disease in our exploratory pilot study. The high circulating amino acid levels can be predictive of coronary artery disease in our multivariate models. Full article