Isolated internal iliac artery infected pseudoaneurysm occlusion using endovascular coil embolisation

A 34-year-old man presented with painful swelling in the right gluteal region. The MRI showed right sacroiliitis and adjacent intramuscular abscess. The abscess was drained by a pigtail insertion followed by incision and drainage. The patient developed persistent bleeding from the drainage site. CT angiogram revealed a large pear-shaped pseudoaneurysm arising from the anterior branch of the right internal iliac artery. The patient had Abrus precatorius poisoning previously resulting in methicillin-resistant Staphylococcus aureus septicaemia, which incited above events. Digital subtraction angiography with coil embolisation of the right internal iliac artery was done under the cover of culture-specific antibiotics along with thorough wound debridement following which the patient’s condition improved. Isolated infected pseudoaneurysms of internal iliac arteries, although rare, should be considered in cases of complicated sacroiliitis. Under antibiotic cover, endovascular coil embolisation can be considered as a treatment strategy to treat complicated infected pseudoaneurysms located in difficult anatomical locations.

Frequency and structure of cardiac arrhythmias in the early postoperative period following cardiac surgery

Funding Acknowledgements Type of funding sources: None. Background. Cardiac arrhythmias occupy one of the key places in the structure of complications of the early postoperative period following cardiac surgery. According to various literature sources, they range from 10% to 40% and often determine the course of the postoperative period. Purpose. To determine the frequency and structure of cardiac arrhythmias in the early postoperative period in the patients following cardiac surgery (up to 7 days). Methods. 56 patients were examined, among them 19 (33.9%) men and 37 (66,1%) women (p = 0.02). The age of patients ranged from 31 to 79 years, averaging 60.86 ± 8.87 years. Cardiac surgery was performed for coronary heart disease in 37 (66.1%) and valvular heart defects in 19 (33.9%) patients (p = 0.02). The duration of the operation ranged from 240 to 600 minutes, averaging 371.94 ± 102.04 minutes. In 25 (44.6%) cases, the operations were performed in conditions of bypass, the average duration of which did not differ from operations without bypass (389.44 ± 116.88 vs. 355.47 ± 86.16, p = 0.34). Assessment of cardiac arrhythmias was performed during the first 7 days after cardiac surgery. Statistical processing was performed by SPSS 12.0 for Windows. Results. 27 (48.2%) patients have developed arrhythmias within first 7 days of the postoperative period, among them in 12 (63.2%) women and 15 (40.5%) men (p = 0.24). Analysis of age structure showed that the patients <45 years didn’t have arrhythmias, 45-59 years - 8 (14.2%), 60-74 - 17 (30.4%), 75-90 - 2 (3,6%) of the patients have rhythm disorders, respectively. Atrial fibrilation (AF) dominates in the structure of arrhythmias - 17 (30.4%) patients, among them – in 11 (64.7%) patients was paroxysmal, in 6 (35.3%) – persistent form. The mean score of CHA2DS2VASc scale - 2.56 ± 0.89. Also registered atrial flutter – in 3 (5.4%), atrial tachycardia – in 2 (3.6%), supraventricular paroxysmal tachycardia – in 1 (1.8%), frequent supraventricular premarute beats (PB) – in 11 (19.6%) ), ventricular PB – in 12 (21.4%), among them ventricular PB 1st Laun class - 8 (66.7%), 2nd class - 2 (16.7%), 3rd class - 1 (8.3%), class 4A - 1 (8.3%) patients, respectively. Among the heart blocks were registered left bundle branch (LBB) block – in 4 (7.1%), anterior branch block of LBB – in 10 (17.9%), right bundle branch block – in 6 (10.7%), atrio-ventricular (AV) block 1 degree – in 4 (7.1%), complete AV block – in 8 (14.3%) patients, respectively. The implantation of the pacemaker was performed in 9 (16.1%) patients. Disorders of repolarization flattening / inversion of the T wave – in 31 (55.4%), elevation of the ST segment – in 5 (8.9%), depression of the ST segment – in 16 (28.6%), pathological Q wave – in 5 (8.9%) patients, respectively. Conclusions The prevalence of arrhythmias in the early postoperative period (7 days) following cardiac surgery is 48.2%, equally common in men and women. AF dominated in the structure of cardiac arrhythmias (30,4%).

The Relationship Between Arm Abduction Position and the Risk of Iatrogenic Anterior Branch of the Axillary Nerve Injuries: A Cadaveric Study

Background: The axillary nerve is at risk for iatrogenic injuries in surgical procedures involving the lateral aspect of the shoulder joint. To date and to our knowledge, there have been no studies that have compared the relevant distances in the common arm abduction positions used in these types of surgery as well as the relative risks of each position. Purpose: To evaluate the effect of arm abduction position on the distance from the acromion process to the axillary nerve in the common abducted arm positions. Study Design: Descriptive laboratory study. Methods: The shoulders of 10 fresh-frozen, full-body cadaveric specimens were used. A saber incision was made at the anterolateral edge of the acromion, and the anterior branch of the axillary nerve was identified. The distance between the anterolateral edge of the acromion process and the axillary nerve was measured 3 times in each of 4 positions: with the arm at the side as well as at 30°, 60°, and 90° of abduction. Then, the same procedure was performed from the midlateral and the posterolateral edges of the acromion process. The distances of the acromion process to the axillary nerve in the 4 positions were compared using 2-way analysis of variance. Results: The mean distances from the anterolateral edge of the acromion process to the anterior branch of the axillary nerve were 52.76 ± 4.64 mm with the arm at the side, 49.48 ± 4.77 mm at 30° of abduction, 46.00 ± 4.75 mm at 60° of abduction, and 42.88 ± 4.59 mm at 90° of abduction. There was a significant decrease in the distance from the anterolateral edge of the acromion process to the axillary nerve as the abduction angle of the arm increased from 0° to 60°, 0° to 90°, and 30° to 90° ( P < .05). Conclusion: The distances from the acromion process to the axillary nerve were shorter in all abducted arm positions than with the arm at the side. Clinical Relevance: To avoid iatrogenic axillary nerve injuries, surgeons should be aware of the safe zone based on the shortest distance from the acromion process to the axillary nerve to ensure no accidental damage to this structure instead of using the mean distance of 5 cm.

Morphological and Morphometric Study of Pterion in Adult Dry Human Skulls

Introduction: Pterion is significant bony landmark because it commonly lies near the anterior branch of middle meningeal artery as well as Broca’s Area. The aim is to study the types of pterion and measure the distance from various bony landmarks on skull to the midpoint of pterion. Subjects and Methods: This study was performed on 70 adult dry human skulls of unknown age and sex. Types and location of pterion was observed bilaterally. Measurements were taken in millimeter using digital Vernier caliper from midpoint of pterion to i) fronto-zygomatic suture ii) middle of zygomatic arch iii) tip of mastoid process iv) glabella v) antero-superior margin of external acoustic meatus vi) Asterion. Results: We observed five types of pterion: spheno-parietal, fronto-temporal, stellate, epipteric and atypical. Among the skulls studied the most common type was sphenoparietal bilaterally. The mean of distances from midpoint of pterion to fronto-zygomatic suture was, 31.68 5.58 mm and 31.18 5.82 mm; to the middle of zygomatic arch was 38.87 3.63 mm and 37.84 3.99 mm; to asterion was 83.55 7.22 mm and 85.53 6.88 mm; to external acoustic meatus it was 51.70 3.20 mm and 51.37 3.39mm; to glabella it was 77.24 6.93 mm and 76.44 6.83 mm; to tip of mastoid process it was 80.77 6.10mm on the right side and 79.59 5.70 mm on the left side. Conclusion: Pterion is the most commonly used surface landmark. Findings of present study regarding classification of pterion will be helpful for neurosurgeons, radiologists, anthropologists and forensic pathologists.

The “branching external jugular vein”: an unreported clinically significant anatomic variation

Background The reported overall success rate for central venous catheter (CVC) insertion into the external jugular vein (EJV) is less than other central veins. A contributing factor for this might be the well-documented anatomical variations of the EJV. However, there are no reports correlating these anatomical variations with successful CVC insertion. Our aim was to evaluate the EJV anatomical variations and their clinical relevance. Results All CVCs inserted over the study period were prospectively recorded with emphasis on the times the EJV was accessed, operative difficulties and any anatomical variations with their influence on CVC insertion. Over 15 months, 36 CVCs were inserted, 17 (47%) into EJV. For EJV line insertions, age is 39 days–14 years, 9 into right EJV. Operative difficulty was encountered in 4 patients (24%) where the catheter was inserted into EJV but failed to thread into a satisfactory position. In all 4 patients, further dissection revealed EJV branching into a bigger anterior branch which follows the course of main EJV yet not leading to the right atrium (RA) and a smaller posterior branch leading to RA. Regarding the 4 cases of “the branching EJV”, age is 2–14 years, 3 males:1 female and 3 left:1 right EJV. The overall success rate for CVC insertion through the EJV in this study was 100% including the 4 cases with “the branching EJV”. Conclusions This is the first report describing “the branching EJV” and its clinical relevance to CVC insertion.