Transcatheter Closure of a Large Muscular Ventricular Septal Defect (VSD) in a Child Weighing Five Kilogram with Severe Pulmonary Arterial Hypertension

Ventricular septal defect (VSD) is the commonest congenial heart lesion which may close spontaneously in significant number of cases. Muscular VSD has better chance of spontaneous closure. Some of the large muscular VSDs may cause severe complications like pulmonary hypertension and intractable heart failure. Closing VSD in young infant is challenging specially with devices as delivery systems are too large comparing to size of femoral vessels. Some centre prefers hybrid procedure of per ventricular device closure as surgical closure is high risk in young infants with complications. Here a case of large muscular VSD with severe pulmonary hypertension is reported in a ten month old girl which was closed successfully with a Konar- MFTM device and patient was discharged after 24 hours. JAFMC Bangladesh. Vol 16, No 2 (December) 2020: 84-86

Eponymous terms and rarities

This chapter provides a list of eponymous terms and rare diseases. These include acanthosis nigricans, which is pigmentation of the axillary skin associated with breast or gastric cancer; Baker’s cyst, which is almost always associated with knee joint pathology such as arthritis or torn meniscus; and Cloquet’s (Callisen’s) hernia, which is a deep femoral hernia that cannot protrude from the saphenous opening as it lies deep to the femoral vessels. The chapter then deals with DeQuervain’s disease, encephalocele, and familial adenomatous polyposis (FAP). It also describes gamekeeper’s thumb, hereditary osteodystrophy, inspissated bile syndrome, Jansen’s disease, Kaposi’s sarcoma, and livedo reticularis. Finally, the chapter defines McMurray’s test, which is used to identify medial meniscal tears; nutcracker oesophagus, which is an alternative name for diffuse oesophageal spasm; and osteogenesis imperfecta, which is an inherited collagen disorder, resulting in fragile bones that fracture easily, blue sclera, deafness, and soft teeth.

Lymphatic complications after harvesting venous conduits in coronary artery bypass grafting surgery

Complications associated with the disorders of lymphatic outflow in the lower extremities are common in cardiovascular surgery involving the isolation of venous conduits and interventions on the femoral vessels. Despite the relatively low frequency, treatment of these complications requires significant efforts and does not always yield the expected results whereas timely diagnosis of lymphatic drainage disorders is often difficult. This becomes the reason for repeated hospitalizations, surgical interventions, long hospital stays, and disabilities. However, the problem of lymphatic complications is still not getting enough attention. This article discusses the pathogenesis, predictors of lymphatic complications, and the options and approaches to their treatment and diagnosis.

823 The ‘Blue Blood' Chicken Thigh Model: Microsurgery Simulation Teaching for Surgical Trainees

Introduction The simulation of microsurgery via various models helps surgical trainees to further their instrument handling and techniques. This model allows trainees to strengthen hand-microscope-eye coordination; a crucial ability required when handling critical vessels and tissues. The ‘Blue Blood’ Chicken Thigh Model imitates delicate vessels enabling the enhancement of dexterity. Aim To raise awareness amongst trainees in how the model may be used as a simulation tool for learning. To outline the arrangement of the ‘Blue Blood’ chicken thigh model allowing the practice of exceptionally fine suturing such as end-end anastomosis and end-side anastomosis. To improve trainee confidence in instrument handling and technique. Method A Microsurgery course was set up for maxillofacial surgical trainees within the West Midlands Deanery in November 2019. Detailed steps of dissecting the femoral vessels and preparing the ‘Blue Blood’ Chicken Thigh Model were presented. Microsurgical tools were then used to practise end-end and end-side anastomosis. Results The feedback received from the trainees was positive and it is hoped this will become an annual session for all trainees. Many trainees felt this was a resourceful tool to help them practise - even at home. Conclusions It is important for trainees to be able to display precise hand-eye movements especially when concerned with anastomosis techniques. This model will allow trainees to be able to simulate such an environment outside of theatre where they can spend time to hone skills and become comfortable with handling finer tissues and instruments.

Venoarterial Extracorporeal Membrane Oxygenation via Direct Axillary Artery Cannulation

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is an effective means of support for patients awaiting cardiac or cardiopulmonary transplantation. Typically, peripheral cannulation via the femoral vessels is preferred. However, an alternative is use of the axillary or subclavian artery, which is typically performed via a graft. Here we present the case of a patient who required VA-ECMO for cardiogenic shock with severe pulmonary hypertension as a bridge to heart-lung transplantation. Initially cannulated via the femoral artery, he was converted to a direct axillary cannulation strategy with a distal perfusion catheter and successfully bridged to transplantation. This technique avoids the use of an interposition graft and mitigates problems associated with it.

Necrotizing Fasciitis Causing Complete Femoral Vessels Necrosis and Thrombosis in an Intravenous Drug Abuser: A Case Report

Background: Intravenous drug abuse is an anciently known health and social problem worldwide. The nonsterile application of addicting drugs leads to severe life-threatening vascular complications. The femoral triangle is an easy target for this purpose. Groin necrotic fasciitis (NF) with vessel necrosis is a challenging diagnosis that requires prompt treatment. Case Report: A 44-year-old male intravenous drug user presented for a left groin pain. He was diagnosed by computed tomography scan to have necrotizing fasciitis. Urgent debridement was performed and identified infected and necrotic ruptured femoral vessels without active bleeding. Debridement with vessel ligation was performed, and delayed revascularization was planned. The patient was admitted six weeks later with a left fifth toe necrosis and delayed arterial revascularization was performed via extra-anatomic trans-obturator ilio-femoral anastomosis. The patient had a favorable follow-up. Conclusion: NF in intravenous drug abusers should always be taken into consideration when a patient presents with groin pain and swelling. Urgent surgical control should be established. Extra-anatomical trans-obturator ilio-femoral anastomosis is a good option for revascularization.

Peripheral vascular access from the arms for electrophysiology procedures using ultrasound guidance

Introduction Vascular access has traditionally been gained from the femoral vessels, however, a ‘radial-first’ approach has become increasingly popular and resulted in lower complication rates and reduced healthcare costs. A “superior” approach has been reported for electrophysiology (EP) studies but is associated with an increased risk. To provide comprehensive anatomical evidence that the vessels of the arms are suitable for use during EP procedures, as assessed by vascular ultrasound. Methods A portable ultrasound device was used to measure the diameter of the brachial artery, brachial, basilic & cephalic veins on the left and right upper limbs of 63 healthy volunteers. A subgroup of 15 volunteers had additional measurements taken with a tourniquet. Results The basilic vein had the largest diameter with a median of 4.6 mm and 4.5 mm (right and left diameter, respectively), followed by the cephalic (median of 3.1 and 3.0 mm) and the brachial vein (median of 2.8 mm). 100% of volunteers had at least one vein that was equal to a 3 mm diameter (which would allow for an 8F sheath), with 98% having 2 suitable veins and >80% having 3 suitable venous vessels. More than 90 % had a suitable diameter for both the right and left brachial artery. There was no correlation between BMI, height, weight, but men had significantly larger basilic veins and brachial arteries (p<0.05). Conclusion We demonstrate the anatomic evidence that the vessels in the arm(s) are capable of housing the size of sheath commonly used in the EP lab.

Alternative option for limb reperfusion cannula placement for percutaneous femoral veno-arterial ECMO

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is an established last line support for severe, acute cardiorespiratory failure. In the case of VA ECMO, peripheral cannulation via the femoral vessels is often advantageous when compared with the alternative central cannulation, and is associated with better clinical outcomes. One of the specific potential complications of peripheral femoral arterial cannulation for ECMO, however, is ipsilateral distal lower limb ischemia; a consideration especially when cannulating the vessel directly, as distal limb perfusion is invariably compromised by an occlusive effect of the arterial cannula within the femoral artery. The gold standard technique for lower limb reperfusion is a separate size 6–7 Fr cannula inserted proximally into the femoral artery, just below the insertion point of the ECMO return cannula, and connected directly to the ECMO circuit so that the blood flow is also directed distally to perfuse the entire limb. This functions well whether the ECMO cannula has been placed percutaneously or by surgical cut-down. Although proximal femoral arterial placement of the reperfusion cannula is the established and preferred technique, there are many technical challenges which may preclude its placement. Local haematoma or bleeding post ECMO insertion, peripheral vascular disease, constricted vasculature in severely shocked patients, or patient obesity are all common reasons why placement of the proximal reperfusion cannula may be difficult, or impossible. In such instances, our retrograde perfusion technique may maintain limb perfusion and may even be limb saving for patients on VA ECMO support.

PHENOMENON OF DEMIKHOV. In the Sklifosovsky Institute (1960–1986). Demijоv V.P. Transplante experimental de órganos vitales. Madrid: Editorial Atlante, 1967

For the first time, the article introduces into scientific circulation and analyzes the Preface by V.P. Demikhov to his book "Transplantation of vital organs in experiment", published in 1967 in Spanish under the title "Transplante experimental de órganos vitales". Judging by the facts mentioned in the text, V.P. Demikhov wrote it in 1966, reflecting his views on the current state and prospects of homoplastic tissue and organ transplantation. As in previous publications, in particular, in the Preface to the German edition of the book published in Berlin in 1963, V.P. Demikhov substantiated the concept that the main condition for a successful transplantation of homoplastic organs was to restore the blood circulation in them. In his opinion, the success of engraftment depends, first of all, on the ideally performed vascular suture and the immediate inclusion of the transplanted donor organ into the blood circulation of the host body, as well as on the sterility of the undertaken intervention. Having discussed the use of pharmacological immunosuppression as a method of overcoming the biological incompatibility of homologous organs during their transplantation, V.P. Demikhov pointed out the toxicity of the drugs used for this purpose he tested experimentally, as well as his experiments, indicating the possibility of overcoming incompatibility by means of other methods (the selection of the donor and recipient with regard to the blood group, mixing the blood of the donor and recipient by parabiosis, etc.). In this text V.P. Demikhov again mentioned the scheme he had developed for two-stage transplantation of an additional heart as a reserve organ to maintain the function of the patient's decompensated heart and named the main stages of the operation: implantation on the femoral vessels (stage 1) and transplantation into the chest (stage 2). As in the Preface to the German edition of the book, V.P. Demikhov spoke in detail about the model of a “living physiological system” he had developed in 1963 aimed at creating a bank of reanimated organs that would retain their viability until transplanted into another body. Projects for growing the organs in anencephalic newborns for the rejuvenation of the elderly were also outlined.