Search Results (237)

Background/Objectives: This article discusses the clinical–surgical relevance of vascular anatomical variations, such as fenestrations—the division of a vessel into multiple channels that subsequently rejoin distally. Although rare in peripheral veins, these variations, which originate from the incomplete condensation of the embryonic capillary plexus, can predispose thrombosis and necessitate preoperative recognition to avert complications during routine procedures. This study aims to report a rare case of dual origin and double fenestration of the cephalic vein. Methods: During a cadaveric dissection, a variation of the cephalic vein was identified. Results: In this case, an origin of the cephalic vein was observed arising from the dorsal venous network of the hand. It exhibited a double fenestration in the forearm, where a branch of the medial cutaneous nerve of the forearm perforated it before draining into the brachial vein. The second, a proximal origin, arose from the convergence of two tributaries—one originating from the subcutaneous tissue lateral to the brachial muscle and the other from the biceps brachii muscle, forming a single trunk that drained into the subclavian vein. Conclusions: This rare variation of the cephalic vein (dual origin and fenestration) carries significant hemodynamic implications, including an increased risk of turbulence and thrombosis. The atypical anatomical relationship between the nerve and the fenestrated vein also heightens the potential for iatrogenic injuries. In-depth knowledge of such anomalies is crucial for healthcare professionals to minimize complications and optimize the success of procedures like venous access and arteriovenous fistulas, ultimately ensuring patient safety. Full article

Background: Primary spinal gliomas are rare in the pediatric population. Separately, FGFR1 genomic aberrations are also uncommon in spinal cord tumors. We report a case of a previously well adolescent who presented with progressive symptoms secondary to an intramedullary tumor with unique radiological and molecular characteristics. Case Presentation: A previously well 17-year-old male presented with worsening mid-back pain associated with lower limb long-tract signs. Magnetic resonance imaging (MRI) of his neuro-axis reported a long-segment intramedullary lesion with enhancing foci and a multi-septate syrinx containing hemorrhagic components from C4 to T12. The largest enhancement focus was centered at T7. Additional MRI sequences observed no intracranial involvement or vascular anomaly. He underwent an emergent laminoplasty and excision of the thoracic lesion. Intraoperative findings demonstrated a soft, grayish intramedullary tumor associated with extensive hematomyelia that had multiple septations. Active fenestration of the latter revealed blood products in various stages of resolution. Postoperatively, the patient recovered well, with neurological improvement. Final histology reported a circumscribed low-grade glial neoplasm. Further molecular interrogation via next-generation sequencing panels showed FGFR1 p.K656E and V561M alterations. The unique features of this case are presented and discussed in corroboration with a focused literature review. Conclusions: We highlight an interesting case of an intramedullary tumor with unusual radiological and pathological findings. Emphasis is on the importance of tissue sampling in corroboration with genomic investigations to guide clinical management. Full article

This research investigates the integration of green cores as central biophilic elements in residential architecture, proposing a climate-responsive design methodology grounded in architectural optimization. The study begins with the full-scale refurbishment of a compact urban apartment, wherein interior partitions, fenestration and material systems were reconfigured to embed vegetated zones within the architectural core. Light exposure, ventilation potential and spatial coherence were maximized through data-driven design strategies and structural modifications. Integrated planting modules equipped with PAR-specific LED systems ensure sustained vegetation growth, while embedded environmental infrastructure supports automated irrigation and continuous microclimate monitoring. This plant-centered spatial model is evaluated using quantifiable performance metrics, establishing a replicable framework for optimized indoor ecosystems. Photosynthetically active radiation (PAR)-specific LED systems and embedded environmental infrastructure were incorporated to maintain vegetation viability and enable microclimate regulation. A programmable irrigation system linked to environmental sensors allows automated resource management, ensuring efficient plant sustenance. The configuration is assessed using measurable indicators such as daylight factor, solar exposure, passive thermal behavior and similar elements. Additionally, a post-occupancy expert assessment was conducted with several architects evaluating different aspects confirming the architectural and spatial improvements achieved through the refurbishment. This study not only demonstrates a viable architectural prototype but also opens future avenues for the development of metabolically active buildings, integration with decentralized energy and water systems, and the computational optimization of living infrastructure across varying climatic zones. Full article

Endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) requires multidisciplinary expertise to minimize mortality and disabling complications. Despite satisfactory outcomes with this approach being common knowledge, extensive aortic coverage occurring in fenestrated/branched endovascular aortic repair (F/B-EVAR) carries a non-negligible risk of spinal cord ischemia (SCI). Recently, many authors have proposed different endovascular strategies to mitigate the risk of SCI; however, the real effectiveness of these maneuvers is not universally recognized due to a lack of standardized protocols among individual centers. Several adjuncts have been proposed to obtain staged occlusion of segmental aortic branches to promote spinal cord preconditioning. These strategies include proximal thoracic aortic repair (PTAR), temporary aneurysm sac perfusion (TASP), and minimally invasive staged segmental artery coil embolization (MIS²ACE). The present paper aims to provide an overview of the most advanced staging strategies used in high-volume aortic centers, pointing out that it takes meticulous preoperative planning to face every clinical scenario. Full article

Background: Laparoscopic subtotal cholecystectomy (LSTC), either fenestrating or reconstituting, offers potential benefits for the “difficult gallbladders” in terms of reduced bile duct injury (BDI) risk. Methods: This single-center retrospective cohort study analyzed data from patients who underwent reconstituting or fenestrating LSTC at a tertiary care center. We excluded patients who were converted to open cholecystectomy or had incomplete medical records. The data examined included demographic and clinical characteristics, preoperative assessments, operative details, and postoperative outcomes. No multivariable regression was performed because of the limited sample size. Results: The study included 46 patients (reconstituting: 20 patients; fenestrating: 26 patients). The severity of cholecystitis assessed by the Tokyo guidelines showed a higher proportion of Grade 2 severity in the reconstituting group than the fenestrating group (90% vs. 56.5%; p = 0.027). Both surgical techniques were similarly challenging and showed no significant differences in operative difficulty, operative duration, blood loss, or total hospital stay. Fenestrating procedures had non-significantly higher incidences of BDI (7.7% vs. 0%; p = 0.21), bile leakage (23.1% vs. 10%; p = 0.246), and intraoperative drain placement (88.5% vs. 75%; p = 0.232). Postoperative complications such as bile leaks were also comparable between the two techniques. Nevertheless, given the small sample, these observations are descriptive and should not be interpreted as evidence of comparability or superiority. Conclusions: Despite limitations, our analysis suggests that fenestrating and reconstituting approaches have comparable postoperative outcomes, although fenestrating procedures were associated with slight but non-significant increases in BDI and drain placement due to leaks. The choice of LSTC technique should depend on intraoperative findings, surgical expertise, and familiarity with each technique, but further studies are needed to obtain firm conclusions. Full article

This study aims to create environmentally comfortable building designs in hot and dry steppe climates using more effective approaches. The purpose of this study is to assess the relationship between mean radiant temperature (MRT) and indoor air temperature (Tia), taking into account the orientation of buildings, for better building thermal performance. For this purpose, residential buildings with different orientations were selected in the study region ‘Garmian—northern Iraq’, and their thermal performance was evaluated. The results show how MRT contributes to the buildings’ thermal comfort. The outcomes of this research provide innovative empirical quantification of the correlation of MRT-Tia, as the regression coefficient (β) represents the rate of change in Tia per unit increase in MRT and ranges by orientation in the study area. The findings demonstrate that north-facing buildings buffer radiant heat gain (β~0.52), resulting in a 0.5 °C increase in indoor air temperature for each 1 °C rise in MRT. Moreover, west orientation delivers promising winter passive heating (MRT up to 22 °C and indoor air temperature up to 22.8 °C with a β of ~0.82). However, south-facing buildings perform poorly in the winter, with low MRT and a weak β (~0.44), contrasting with passive solar design strategies that favor south-facing buildings in the northern hemisphere. Furthermore, in the summer, the MRT is always higher than Tia, while it is lower in winter, indicating poor envelope and fenestration thermal insulation properties, which lead to excessive energy usage to maintain thermal comfort. Finally, the study suggests the novel quantified MRT-Tia mathematical correlation responds to the orientations for such climates, offering both diagnostic and predictive tools for thermal comfort performance optimization. This study is the first to empirically quantify orientation-specific MRT–Tia relationships in BSh climates, offering a novel diagnostic tool for sustainable building design. This study involved field observations in 36 residential row houses across four orientations. Key environmental and personal variables measured included mean radiant temperature (MRT), indoor air temperature (Tia), air velocity, relative humidity, metabolic rate, and clothing insulation. Full article

Atherosclerosis (AS), the leading cause of cardiovascular disease (CVD), is the thickening and stiffening of arterial walls, mainly of coronary arteries, the aorta, and the internal carotid artery. Blood flow is restricted by the deposit of lipid-rich macrophages (foam cells), calcium, fibrin, and cellular debris into plaques on the inner lining (tunica intima) of arterial walls. Damaged endothelia become inflamed and accumulate macrophages, monocytes, granulocytes, and dendritic cells, which intensifies plaque formation and increases the risk of myocardial infarction (MI) and thrombosis. Many of the anatomical and physiological abnormalities in arterial walls can be linked to colonic bacteria that produce inflammation-inducing metabolites, e.g., succinate, fumarate, fatty acids (FAs), reactive oxygen species (ROS), lipopolysaccharides (LPS), and trimethylamine-N-oxide (TMAO). TMAO triggers platelet formation, inhibits the synthesis of bile acids (BAs), accelerates the formation of aortic lesions, and upregulates the expression of membrane glycoprotein CD36 (also known as platelet glycoprotein 4) on the surface of platelets and epithelial cells. The ability of internal mammary arteries (IMAs) to produce higher levels of apolipoprotein C-III (apo-CIII) and paraoxonase (PON), compared to coronary arteries, prevents plaque buildup. The tunica intima of IMAs is rich in heparin sulfate and endothelial nitric oxide synthase (eNOS). Increased production of NO relaxes VSMCs and suppresses GTP cyclohydrolase (GTPCH), which lowers blood pressure. Higher levels of prostacyclin (PG12) produced by IMAs inhibit platelet aggregation. IMAs are structurally different from coronary arteries by having a thinner, non-fenestrated, tunica intima without a prominent internal elastic lamina. These characteristics render IMAs ideal conduits in coronary artery bypass graft (CABG) surgery. This review provides information that may explain why IMAs are less affected by inflammatory reactions and more resilient to plaque formation. Full article

Background: Advances in stent grafts and endovascular techniques have expanded the indications for thoracic endovascular aortic repair (TEVAR) to include arch lesions. In situ needle fenestration (ISNF) has emerged as a promising technique for revascularizing supra-aortic branches. The aim of this study is to evaluate the safety and efficacy of triple in situ needle fenestration during TEVAR for aortic arch pathologies in a single-center experience. Materials and Methods: A retrospective analysis was conducted on fifteen patients who underwent in situ triple fenestration TEVAR between June 2023 and March 2024. The median age of the patients was 51,33 years (±19.69) and twelve of the patients were male. All procedures were performed under general anesthesia in a hybrid operating room. Ethical approval was obtained from the institutional review board, and informed consent was received from all participants. Results: Primary technical success was achieved in all cases (15/15, 100%). The mean operation time was 197.33 min (range: 126–302). Two patients experienced a minor hematoma at the access site. Mortality was observed in one patient (6.66%) during the 30-day follow-up period. The total hospital stay averaged 7 ± 3.36 days. One patient had a transient ischemic attack, but there were no incidents of stroke or spinal cord ischemia. No procedure-related endoleak was observed during the intervention; however, eight patients required reintervention in the descending aorta. Conclusions: ISNF may be an effective and feasible method for revascularizing arch vessels, with low rates of early mortality and stroke when performed by experienced practitioners. However, larger multicenter studies with longer follow-up are needed to confirm the durability and long-term outcomes of this technique. Full article

The internal jugular vein (IJV) is of utmost importance during various surgical and endovascular approaches, including central access. It descends through the parapharyngeal space, carotid triangle, and sternocleidomastoid region. The anatomical variables of the IJV are mainly related to its calibre and dominance, number of venous channels (i.e., duplications and fenestrations), and compression sites. Specific compressions of the IJV are not exclusively due to the jugular nutcracker between the styloid process (SP) of the temporal bone and the C1 transverse process, which, in turn, should not be granted the eponym of Eagle. The possible morphologies of the SP and ossified stylohyoid chain are discussed here. Additionally, the digastric and sternocleidomastoid muscles, the hyoid, and the distorted carotid arteries may compress the IJV, thereby raising intracranial pressure. Here, a case is documented with a long inferior petrosal sinus adjacent to the IJV, both compressed into the C1–styloid nutcracker, which is an absolute novelty. Multiple compression sites of the IJV are supported here with original evidence. All anatomical variables of the IJV are relevant, as they may lead to stenoses or interfere with IJV cannulation. In rare cases of IJV agenesis, multiple compression sites on the opposite side may significantly alter bilateral cerebral drainage. Different methods may be used to decompress a stenotic IJV, including styloidectomy. In conclusion, the anatomical variables of the IJV should be acknowledged by practitioners and documented on a case-by-case basis. Full article

This study examines the influence of vegetation on indoor daylight performance in school buildings located in the hot–humid climate of Chennai, India. With increasing urban development leading to the cutting or relocation of trees, their role in modulating interior daylight conditions has become critically relevant but remains underexplored in the literature. Recognizing a significant research gap in this area, this study employed a simulation-based approach using DesignBuilder 7.4 software. A government school in South Chennai, India, was chosen for this study. A total of 208 scenarios were generated by varying the window-to-wall ratio (WWR), facade orientation, floor level, and tree presence. Daylight performance was evaluated using spatial daylight autonomy (sDA), annual sunlight exposure (ASE), and useful daylight illuminance (UDI), based on IES LM-83-12 and LEED v4 standards. Simulation results showed that a 20% window-to-wall ratio (WWR) failed to meet daylight standards, while a 30–40% WWR with shading consistently performed well. Trees significantly improved daylight metrics, like sDA, UDI, and ASE, more so than orientation or floor level. This study urges regulatory mandates for climate-resilient schools, emphasizing fenestration and landscape integration. Full article

Background: Endometriosis is a chronic disease defined by the presence of endometrial-like tissue outside the uterine cavity. While typically confined to the pelvis, extrapelvic manifestations—including thoracic endometriosis—can occur. Although rare, thoracic endometriosis is the most common extragenital form. In clinical practice, this presentation is often described as thoracic endometriosis syndrome (TES), a constellation of cyclic thoracic symptoms temporally associated with menstruation but not always histologically confirmed. Its atypical symptoms and limited clinical awareness frequently lead to delayed diagnosis, mismanagement and increased patient burden. Methods: In accordance with the CARE guidelines, we present a case report of a female patient with thoracic endometriosis syndrome, emphasizing the prolonged interval between symptom onset and final diagnosis. Case Report: We describe a 42-year-old woman with a longstanding history of dysmenorrhea and menorrhagia, who developed cyclical chest pain and dyspnea in 2019. Despite multiple thoracoscopic procedures, her symptoms persisted and were repeatedly misattributed to anxiety or infection. Thoracic endometriosis syndrome (TES) was suspected in 2022, and although histopathological confirmation was lacking, intraoperative visualization revealed diaphragmatic fenestrations. In 2025, a second laparoscopic intervention targeting the abdominal surface of the diaphragm resulted in significant symptom relief. The patient is currently continuing hormonal therapy with Dienogest and has reported a marked improvement in quality of life. Nevertheless, the protracted diagnostic and therapeutic process—marked by chronic pain and repeated hospitalizations—had a profound psychosocial impact, culminating in a suicide attempt. Conclusions: This case illustrates the substantial burden associated with the delayed recognition of thoracic endometriosis syndrome and the consequences of fragmented care. The patient’s experience underscores the urgent need for coordinated, multidisciplinary management and psychological support, particularly for patients with extrapelvic manifestations. Early multidisciplinary evaluation, with readiness to consider surgical intervention alongside individualized hormonal therapy, may support improved outcomes, provided they are reinforced by increased clinical awareness and systemic improvement in diagnostic pathways. Full article

Background and Clinical Significance: Spinal arachnoid cysts are rare lesions that may become symptomatic through progressive spinal cord compression. We present a complex case of a thoracic extradural SAC in a 17-year-old male, managed through a stepwise, multidisciplinary approach. Case Presentation: The patient presented with progressive lower limb weakness, right knee paresthesia, and urinary hesitancy following physical exertion. MRI revealed a large posterior extradural SAC extending from T2–T3 to T8, with associated spinal cord compression. Initial management involved T8 laminectomy and cyst fenestration under intraoperative neurophysiological monitoring, with partial clinical improvement. However, early recurrence with pseudomeningocele formation prompted a second surgery, including external CSF drainage. Persistent cerebrospinal fluid (CSF) leakage led to targeted epidural blood patching, followed by temporary stabilization. Due to continued cyst enlargement and spinal cord compression, definitive surgical repair was undertaken: fistula clipping at T3 and embolization with platinum coils inside the cystic cavity, combined with a new blood patch. This novel technique resulted in radiological improvement and clinical stabilization. Conclusions: This case highlights the diagnostic and therapeutic challenges of managing symptomatic extradural SACs, particularly in young patients. Our experience underscores the utility of a staged approach involving surgical decompression, neuroimaging-guided interventions, and definitive dural repair. The combination of fistula clipping and coil embolization may offer a promising strategy for refractory cases, potentially reducing recurrence and preserving neurological function. Full article

Liver sinusoidal endothelial cells (LSECs) are essential for preserving liver homeostasis. Metabolic dysfunction-associated steatotic liver disease (MASLD) encompasses a category of hepatic disorders characterized by excessive fat accumulation in the liver, known as steatosis. Over time, accumulated hepatic fat can induce inflammation of the liver (hepatitis). MASLD is among the most prevalent types of chronic liver disease. Obesity and Type 2 diabetes mellitus (T2DM) are frequent etiological factors of MASLD. In the absence of therapy, MASLD can lead to more severe hepatic conditions, which can be life-threatening. MASLD is noteworthy due to its potential progression to MASH and further severe liver impairment, including cirrhosis and hepatocellular carcinoma (HCC), a neoplastic progression. This narrative review examines the distinctive functions of LSECs in regulating immunologic responses, collagenization, and drug-sensitive bioreactivity in healthy livers, MASLD, and metabolic dysfunction-associated steatohepatitis (MASH), as well as in a human primary 3D model. We found that LSECs serve as crucial regulators of immunological equilibrium in the liver by inhibiting disproportionate immunologic activation, concurrently filtering tissue antigens, and engaging with immunologic cells, such as Kupffer cells (KCs) and T lymphocytes. In chronic diseases of the liver, LSECs experience cellular dysfunction, resulting in capillarization (focal to diffuse), loss of fenestrations (fenestrae), and the activation of pro-fibrotic signaling pathways, including transforming growth factor-beta (TGF-β). Indeed, TGF-β is crucial in activating hepatic stellate cells (HSCs), a process that facilitates the progression of liver disease toward fibrosis. In addition to examining the dynamic interplay between LSECs, specifically HSCs, and other liver cells throughout the progression of fatty liver–MASH, we suggest that LSECs may become a potential therapeutic target for modifying immune responses and averting fibrosis in hepatic disorders. The limitations of animal models are also highlighted and discussed. Full article

Background: Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery with cardiopulmonary bypass (CPB) affecting between 5% and 40% of patients, which leads to hemodynamic instability, an increased risk of thromboembolism, decompensated heart failure, prolonged hospitalization, and higher treatment costs. Currently, there are no universally accepted guidelines for preventing POAF. Methods: A single-center, prospective, randomized controlled trial, “The Effect of Colchicine on the Occurrence of Atrial Fibrillation after Cardiac Surgery” (CAFE), ClinicalTrials.gov ID: NCT06798714, was conducted. The study included 140 patients with coronary artery disease randomized into two groups of 70 patients each. Group 1 (control group) received standard postoperative care. Group 2 (intervention group) received colchicine (Colchicum-Dispert at a dose of 500 mcg 4 h before coronary artery bypass grafting (CABG) with CPB and at a dose of 500 mcg twice daily for 10 days postoperatively) and underwent intraoperative pericardial fenestration using an original technique. Results: Perioperative colchicine administration combined with intraoperative pericardial fenestration reduced POAF incidence to 2.9% compared to the control group with POAF incidence of 12.9% (p < 0.05). This management strategy was not associated with an increased incidence of infectious complications, gastrointestinal disorders, or elevated levels of alanine aminotransferase, aspartate aminotransferase, or creatinine. Conclusions: Perioperative colchicine administration combined with pericardial fenestration during CABG with CPB is associated with a reduced POAF incidence, good tolerability, and does not contribute to an increased incidence of infectious complications or impaired liver and renal function. Full article

Background: Kidney-related pain can be chronic, disabling and negatively impact quality of life. In this prospective case series, we assessed whether a stepwise multidisciplinary treatment protocol, originally developed to treat ADPKD-related pain, can provide significant pain relief in non-ADPKD patients with kidney-related pain. Methods: Patients were eligible if they had incapacitating kidney-related pain with a visual analogue scale (VAS) score ≥50 out of 100, lasting ≥3 months and with insufficient response to previous treatments. The main exclusion criterion was ADPKD. Treatment options were, in order when indicated, nonpharmacological treatments, analgesics, cyst aspiration and fenestration, nerve blocks and nephrectomy. The effect of treatment on pain was investigated by means of VAS scores, defined daily dose of pain medication and quality-of-life scores. Results: Twelve patients (67% female, median age 50 [IQR: 36–59] years), with a median duration of pain of 1.9 [1.0–4.7] years, were included. In 50% of cases, chronic pain remained after an acute episode of kidney stones. Median follow-up after treatment was 3.8 [IQR: 2.5–4.4] years. The VAS before treatment (70 (48–90)) was reduced at short-term (35 [28–53], p = 0.01) and long-term follow-up (40 [38–53], p = 0.01). In addition, the defined daily dose of both opioids and non-opioids was reduced at short-term follow-up (p = 0.04 and 0.04, respectively) as well as at long-term follow-up (p = 0.03 and p = 0.02, respectively). Conclusions: We found that our multidisciplinary treatment protocol is effective in achieving sustained pain relief as well as a reduction in the use of pain medication in non-ADPKD patients with chronic, refractory kidney-related pain. Full article