Limb Salvage after Lower-Leg Fracture and Popliteal Artery Transection—The Role of Vessel-First Strategy and Bone Fixation Using the Ilizarov External Fixator Device: A Case Report

Open traumatic lesion of the popliteal artery is relatively rare. Ischemia time longer than 6 h and severity of limb ischemia have been shown to be associated with an increased risk of limb loss. Severe local infection is critical in the presence of major soft tissue trauma or open fractures. We report the case of a young female who suffered a traumatic transection of the popliteal artery associated with an open fracture of the distal tibia and fibula managed by direct vessel reconstruction with an end-to-end repair and skeletal stabilization initially with half-pin external fixation, then replaced by an Ilizarov circular frame. The patient had a very satisfactory outcome, but the fracture healed malunited, later corrected by open reduction and internal fixation with lag-screwing and a neutralization plate.

Segmentation of Liver Anatomy by Combining 3D U-Net Approaches

Accurate liver vessel segmentation is of crucial importance for the clinical diagnosis and treatment of many hepatic diseases. Recent state-of-the-art methods for liver vessel reconstruction mostly utilize deep learning methods, namely, the U-Net model and its variants. However, to the best of our knowledge, no comparative evaluation has been proposed to compare these approaches in the liver vessel segmentation task. Moreover, most research works do not consider the liver volume segmentation as a preprocessing step, in order to keep only inner hepatic vessels, for Couinaud representation for instance. For these reasons, in this work, we propose using accurate Dense U-Net liver segmentation and conducting a comparison between 3D U-Net models inside the obtained volumes. More precisely, 3D U-Net, Dense U-Net, and MultiRes U-Net are pitted against each other in the vessel segmentation task on the IRCAD dataset. For each model, three alternative setups that allow adapting the selected CNN architectures to volumetric data are tested, namely, full 3D, slab-based, and box-based setups are considered. The results showed that the most accurate setup is the full 3D process, providing the highest Dice for most of the considered models. However, concerning the particular models, the slab-based MultiRes U-Net provided the best score. With our accurate vessel segmentations, several medical applications can be investigated, such as automatic and personalized Couinaud zoning of the liver.

Gross Total Resection of a Recurrent in-and-around Cavernous Sinus Meningioma through a Combined Transcavernous Anterior and Middle Infratemporal Fossa Approach with Extracranial-Intracranial Bypass

Objectives The study aims to describe surgical management of an invasive cavernous sinus meningioma with a combination of several skull base approaches and bypass surgery. Design This study is an operative video. Results Resection of the recurrent skull base meningioma is still challenging, especially if the tumor involves or encases the carotid artery. Cerebral bypass surgery is an essential adjunct in the armamentarium of skull base surgery when vessel reconstruction is required. In this paper, we describe our experience of successful treatment of an invasive recurrent skull base meningioma, which involved the entire cavernous sinus and the internal carotid artery. A 46-year-old woman presented with a 2-year history of gradually worsening left-sided exophthalmos and visual impairment. The patient had previously undergone two craniotomies for resection of the left-sided spheno-orbital meningioma. Pathological diagnosis was chordoid meningioma, which is classified as an intermediate-grade meningioma. The second surgery had been performed for a rapid tumor regrowth 6 months after the first surgery. The patient lost her left-side vision after the second surgery. Aggressive tumor regrowth was confirmed with extension into the left orbit, infratemporal fossa, and cavernous sinus with engulfment of the carotid artery. A balloon occlusion test revealed intolerance of the left internal carotid artery occlusion. Considering the patient's age, tumor behavior, and intolerance of the carotid artery of the lesion side, we scheduled gross total resection of the tumor with vessel reconstruction. Conclusion Although cerebral bypass surgery is a technically challenging procedure, it plays an important role in the surgical management of the complex vessel-engulfing tumor.The link to the video can be found at https://youtu.be/GCmpxK3hW18.

Giant internal carotid aneurysm: endovascular parent artery occlusion after failed treatment using a flow diverter—case report

Treatment of giant aneurysms is challenging. While parent vessel reconstruction is the primary therapeutical target, the parent artery occlusion (PAO) is considered the next treatment option. We report a case of a 56-year-old woman with a right-sided non-ruptured giant aneurysm of the cavernous internal carotid artery. After failed aneurysm treatment by vessel remodeling through a flow diverter stent, we decided upon aneurysm coiling and PAO. Prior to the procedure, a successful balloon occlusion test (BOT) was performed, and in the second stage, just before occluding the parent artery, the BOT with induced hypotension was repeated. We achieved a good angiographic result and successful outcome without neurological deficit. In the case of failed treatment of giant aneurysm by vessel reconstruction, PAO is a therapeutical option. Prior to the vessel occlusion, a BOT with induced arterial hypotension challenge should be performed.

Basilar Artery Injury During Endonasal Surgery: Stepwise to Control Bleeding

BACKGROUND Intraoperative injury during endoscopic endonasal surgery of the carotid artery has been previously described in the literature. However, the accidental damage of the basilar artery in such scenario is not defined. OBJECTIVE To define the protocol of action for massive bleeding from an artery in the posterior fossa. METHODS The reported patient was diagnosed with a partially calcified clival chordoma featured by a huge intradural component. An endoscopic endonasal transpterygoid transclival approach was selected for the treatment of this tumor. During the surgical procedure, the basilar artery injury was injured, causing intense bleeding. We present and discuss the surgical maneuvers that could save a patient's life after this dramatic complication. RESULTS Different techniques were performed in order to control the massive bleeding, including injection of hemotastic matrix with thrombin (Floseal©), bipolar coagulation, and vessel reconstruction by means of a vascular clip. Finally, an autologous muscle graft reinforced with an overlying fibrin sealant patch (Tachosil©) was chosen and was an effective technique. Afterwards, the patient was treated with a flow diverter device to occlude an iatrogenic pseudoaneurysm. A monoplegia of the right upper limb was the only remarkable sequel 6 mo after surgery. CONCLUSION The muscle graft together with the coordinated action with interventional neuroradiology for the reconstruction of the vessel are possibly the best options to try to preserve the neurological function. In such a scenario, the assumption of potential ischemic events prevails over the intraoperative death of the patient.