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Vascular ultrasonography. Preoperative vascular ultrasonography at the proximal right upper arm of subject 1 demonstrates high arterial bifurcation of brachial into radial and ulnar arteries. Also seen are 2 radial veins ( ∗ ), one ulnar
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Objective:
Upper extremity (UE) transplantation is the most commonly performed composite tissue allotransplantation worldwide. However, there is a lack of imaging standards for pre- and posttransplant evaluation. This study highlights the protocols and findings of UE allotransplantation toward standardization and implementation for clinical trials...
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Context 1
... veins enhanced within 2 to 3 seconds after arterial opacification. There were 3 arteries in the right upper arm, 2 of which were running almost parallel, possibly early branching radial and ulnar arteries. The third artery curved around the humerus and was most likely the deep brachial artery. In the forearm, at least 3 arteries were observed, most likely the ulnar, radial, and interosseous arteries. Although the basilic vein was well-visualized, the cephalic vein was not identified. Large veins joining the basilic vein, plus collaterals, were observed in the forearm. The findings of CT and MRI were confirmed on vascular ultrasonography ( Fig 2), which in addition demonstrated no significant arterial disease or venous thrombosis. In the second subject, preoperative elbow radiographs demonstrated amputation of the bilateral forearm with hypertrophic changes of the radius and ulnar diaphyses at the stump with no soft tissue abnormality. Catheter angiography demonstrated normal vasculature of bilateral upper extremities with patent axillary, brachial, radial, and ulnar arteries (Fig 3). Preoperative venous mapping by ultrasonography demonstrated patent bilateral subclavian, axillary, cephalic, and basilic veins. In the second subject, immediate postoperative bilateral elbow radiographs demonstrated transplantation at the mid-forearm level with bony fixation using a compression plate and screws. Follow-up imaging excluded hardware complication and demonstrated anatomic alignment with maturing callus formation and osseous bridging (Figs 4 and 5). Dynamic CT and MRI of both transplanted hands demonstrated fingers held in flexion at the ...
Citations
... However, the successful investigation into complete extremity transplantation occurred only after the introduction of cyclosporine in 1982, paving the way for the first successful unilateral hand transplant which occurred in Lyon France in September 1998 [4,5]. Since then, there have been 22 unilateral and 23 bilateral hand transplants recordedby the International Registry of Hand and Composite Tissue Transplantation [6,7]. ...
Objective. To describe the role of imaging in vascular composite allotransplantation based on one institution's experience with upper extremity allotransplant patients. Methods. The institutional review board approved this review of HIPAA-compliant patient data without the need for individual consent. A retrospective review was performed of imaging from 2008 to 2011 on individuals undergoing upper extremity transplantation. This demonstrated that, of the 19 patients initially considered, 5 patients with a mean age of 37 underwent transplantation. Reports were correlated clinically to delineate which preoperative factors lead to patient selection versus disqualification and what concerns dictated postoperative imaging. Findings were subdivided into musculoskeletal and vascular imaging criterion. Results. Within the screening phase, musculoskeletal exclusion criterion included severe shoulder arthropathy, poor native bone integrity, and marked muscular atrophy. Vascular exclusion criterion included loss of sufficient arterial or venous supply and significant distortion of the native vascular architecture. Postoperative imaging was used to document healing and hardware integrity. Postsurgical angiography and ultrasound were used to monitor for endothelial proliferation or thrombosis as signs of rejection and vascular complication. Conclusion. Multimodality imaging is an integral component of vascular composite allotransplantation surgical planning and surveillance to maximize returning form and functionality while minimizing possible complications.
... The first publications [3,4] were sporadic, emphasizing mainly that microsurgical transfer was possible in children. It was not until the mid-1980s that the literature was enriched by larger series [5][6][7][8][9][10][11][12] that was demonstrating the feasibility of performing a variety of microsurgical transplantations in children. ...
Microsurgery in the pediatric population is still challenging because of technical difficulties in the small vessel diameter anastomosis and flaps dissection. The present study reports our experience of microsurgical reconstruction with free tissue transfer and replantation. Twenty-eight pediatric patients under the age of 15 years underwent different microsurgical procedures over a 10-year period. Twenty-one patients (75 %) underwent elective free tissue transfer, while emergency replantation was done in seven patients (25 %). The overall successful microsurgical procedures were 25/28 (89 %). All the 21 free tissue transfers survived (100 %), while three of the seven emergency replantations were lost (57 % survival rate) in this group. Microvascular surgery in children is a feasible, safe, and reliable modality with high survival rate. The indications, success, failure, and complication rates are very near to adults. Over the age of 10 years, procedure is nearly similar to adults. Between the age of 5 and 10 years, successful outcome can be achieved also but with greater challenges in surgical technique. Below the age of 5 years, more challenges could be problematic for successful outcome. Experienced surgical team remains one of the most important factors to obtain good results. Knowledge of multiple reconstructive options and mastering one of them seems essential for satisfactory results.
The vascular reorganization after facial transplantation has important implications on future surgical planning. The purpose of this study was to evaluate blood flow (BF) after full face transplantation using wide area-detector computed tomography (CT) techniques. Three subjects with severe craniofacial injury who underwent full face transplantation were included. All subjects underwent a single anastomosis bilaterally of the artery and vein, and the recipient tongue was preserved. Before and after surgery, dynamic volume CT studies were analyzed for vascular anatomy and blood perfusion. Postsurgical CT showed extensive vascular reorganization for external carotid artery (ECA) angiosome; collateral flows from vertebral, ascending pharyngeal or maxillary arteries supplied the branches from the recipient ECAs distal to the ligation. While allograft tissue was slightly less perfused when the facial artery was the only donor artery when compared to an ECA-ECA anastomosis (4.4 ± 0.4% vs. 5.7 ± 0.7%), allograft perfusion was higher than the recipient normal neck tissue. BF for the recipient tongue was maintained from contralateral/donor arteries when the lingual artery was sacrificed. Venous drainage was adequate for all subjects, even when the recipient internal jugular vein was anastomosed in end-to-end fashion on one side. In conclusion, dynamic CT identified adequate BF for facial allografts via extensive vascular reorganization.
