Case Report: Intra-Tumoral Vaccinations of Quadrivalent HPV-L1 Peptide Vaccine With Topical TLR-7 Agonist Following Recurrence: Complete Resolution of HPV-HR-Associated Gynecologic Squamous Cell Carcinomas in Two Patients

The human papilloma virus (HPV) high-risk variants (HPV-HR) such as HPV16 and HPV18 are responsible for most HPV related cancers, including anogenital and head and neck cancers. Here, we present two patients with HPV-HR-associated gynecological malignancies who, after failing radiation therapy, were treated with experimental salvage immunotherapy regimen resulting in complete, durable responses in both patients. Each patient was diagnosed with recurrent, radiation-refractory, HPV-HR positive, squamous cell carcinoma of the lower genital tract. Patient A was a 90-year-old, African American, with metastatic vulvar cancer to the right inguinal-femoral triangle and pulmonary metastases. Patient B was a 41-year-old, Caucasian, with a central-recurrence of cervix cancer. Each patient received at least two intratumoral quadrivalent HPV-L1 vaccine (Gardasil™) injections and daily topical TLR-7 agonist (imiquimod) to the tumor surface 2 weeks apart. This combination of intratumoral vaccinations and topical TLR-7 agonist produced unexpected complete resolution of disease in both patients. The importance of radiation therapy, despite being considered a treatment failure by current definitions, cannot be understated. Radiation therapy appears to have offered a therapeutic immune advantage by modifying the tumor microenvironment. This immune protocol has potential to help patients with advanced HPV-HR-related malignancies previously considered incurable.

O31 Central venous access in ventilated COVID-19 patients: a vascular surgery perspective

Introduction The number of patients on intensive care units (ICU) increased manifold during the initial COVID-19 surge and medical staff were relocated to help compensate. The need for central venous catheters (CVCs) increased accordingly and comprised a significant workload under challenging circumstances. Several models were proposed to manage the lines. We assigned a vascular team of vascular surgeons and interventional radiologists for CVCs in ICU. We report on the workload, outcomes and lessons learned. Method 50 consecutive ventilated COVID-19 patients in ICU (median age 63 years, 80% male) who had a CVC inserted by the vascular team from March to May 2020 were assessed. Median follow up was 18 days (range 14– 29 days) after ICU admission. Result 166 CVCs (80 VasCaths) were inserted. Femoral access was preferred. Each patient required a median of 3 lines (IQR 2–4). CVCs were exchanged after median 7 days (IQR 4–9) for thrombosis (35%), infection (24%) or prophylactically (41%). Our learning curve included the establishment of an online referral pathway, CVC teams of two operators, extended disposable CVC kits and ICU based ultrasound scanners. Additional staffing and retraining were avoided. There were no technical complications. Conclusion Ventilated COVID-19 patients require multiple CVCs which is a challenging workload during a pandemic. Vascular surgeons and interventional radiologists with endovascular skills are well positioned to perform central venous cannulation to alleviate the burden on critical care teams. Our lessons learned can help to provide a safe and efficient model amidst the ongoing national outbreaks. Take-home Message With the postponement of many elective vascular procedures during the pandemic crisis, the involvement of vascular surgeons in a dedicated Lines team is an important way that they can contribute given their proficiency with wires and cannulation equipment, as well as familiarity in femoral triangle and jugular anatomy. The retraining of staff and additional on-call rotas can then be avoided.

Incidence of Suture-Method Catheter Dislocation with Femoral Nerve Block and Femoral Triangle Block after Total Knee Arthroplasty

Catheter dislocation with continuous peripheral nerve blocks represents a major problem in clinical settings. There is a range of factors affecting the incidence of catheter dislocation, including catheter type. This study aimed to assess the incidence of suture-method catheter (SMC) dislocation 24 h after total knee arthroplasty (TKA), with continuous femoral nerve block (CFNB) and continuous femoral triangle block (CFTB), respectively. In the prospective randomized trial, 40 patients qualified for TKA with SMC and were divided into two groups, those who received CFNB (Group 1, n = 20) and those who received CFTB (Group 2, n = 20). After 24 h, the degree of catheter displacement (cm), pain intensity (NRS) and opioid consumption (mg) was assessed. The catheter dislocation rates were found to be 15% in Group 1 versus 5% in Group 2, with the catheter dislocated by 0.83 cm (SD = ±0.87) and 0.43 cm (SD = ±0.67), respectively. There were no differences in NRS score (p = 0.86) or opioid consumption (p = 0.16) between the groups. In each case, a displaced catheter was successfully repositioned by pulling, which clinically resulted in a lower NRS score. The results of the study suggest that CFTB with SMC may be used after TKA with a good effect, as it is associated with low catheter dislocation rates and an adequate analgesic effect.

Combination of femoral triangle block and infiltration between the popliteal artery and the capsule of the posterior knee (iPACK) versus local infiltration analgesia for analgesia after anterior cruciate ligament reconstruction: a randomized controlled triple-blinded trial

Background and objectivesFemoral triangle block and local infiltration analgesia are two effective analgesic techniques after anterior cruciate ligament reconstruction. Recently, the iPACK block (infiltration between the popliteal artery and the capsule of the posterior knee) has been described to relieve posterior knee pain. This randomized controlled triple-blinded trial tested the hypothesis that the combination of femoral triangle block and iPACK provides superior analgesia to local infiltration analgesia after anterior cruciate ligament reconstruction.MethodsSixty patients undergoing anterior cruciate ligament reconstruction received general anesthesia and were randomly allocated to two groups: femoral triangle block and iPACK under ultrasound guidance or local infiltration analgesia. For each group, a total of 160 mg of ropivacaine was injected. Postoperative pain treatment followed a predefined protocol with intravenous morphine patient-controlled analgesia, acetaminophen, and ibuprofen. The primary outcome was cumulative intravenous morphine consumption at 24 hours postoperatively. Secondary pain-related outcomes included pain scores (Numeric Rating Scale out of 10) measured at 2 and 24 hours postoperatively. Functional outcomes, such as range of motion and quadriceps strength, were also recorded at 24 postoperative hours, and at 4 and 8 postoperative months.ResultsCumulative intravenous morphine consumption at 24 hours postoperatively was significantly reduced in the femoral triangle block and iPACK group (femoral triangle block and iPACK: 9.7 mg (95% CI: 6.7 to 12.7); local infiltration analgesia: 17.0 mg (95% CI: 11.1 to 23.0), p=0.03). Other pain-related and functional-related outcomes were similar between groups.ConclusionsThe combination of femoral triangle block and iPACK reduces intravenous morphine consumption during the first 24 hours after anterior cruciate ligament reconstruction, when compared with local infiltration analgesia, without effect on other pain-related, early, or late functional-related outcomes.Trial registration numberClinicalTrials.gov Registry (NCT03680716).

ANATOMICAL VARIATIONS OF THE ORIGIN OF PROFUNDA FEMORIS ARTERY – A CADAVERIC STUDY

INTRODUCTION: The Profunda Femoris Artery (PFA) is a large branch arises from the lateral or posterolateral part of the Femoral Artery (FA), about 3 to 5cm below the inguinal ligament. The PFA is in close proximity to femoral vessels in the femoral triangle the precise anatomical knowledge of PFA and its branches is of great signicance in preventing profuse haemorrhage, pseudo aneurysms and traumatic AV stulae while doing any procedures or surgeries in that area. AIM & OBJECTIVES: To study the anatomical variations in source of origin, site of origin and distance of origin from midpoint of inguinal ligament of PFA. MATERIALS AND METHODS: The present observational study was conducted on the dissection of 70 lower limbs of 35 adult cadavers (27 male & 8 female) in the Department of Anatomy S.V.S Medical College, Mahabubnagar over a period of 2 years. Contents of the femoral triangle were dissected as per Cunningham's manual. The source of origin, site, distance of origin from mid points of inguinal ligament and course of PFA were noted. Collected data was analysed statistically. RESULTS: In the present study the PFA was arising from the femoral artery in all these 70 Lower Limbs. The commonest site of origin of PFA was postero lateral side of femoral artery in 17 (48.6%) Limbs on right side, 16(45.8%) limbs on left side, followed by lateral side of FA in14(40%) limbs on right side, 12(34.3%) limbs on left side ,followed by posterior in 4(11.4%) limbs on each side. The PFA was originating from medial side of FA only in 3 (4.29%) left limbs The PFA was taking origin below the inguinal ligament most commonly at the distance of 3-4cm in 10(29) limbs on right side, 15(43%) limbs on left side and at 4-5cm in 8(23%) limbs on right side, 5(14%) limbs on left side, at 2-3cm in 8 (23%) limbs on right side, 6(17%) limbs on left side, at 5-7cm in 3(8.5%) limbs on right in 1 (3%) limbs on left side. The PFA was taking origin higher level with in 2cm below the midpoint of inguinal ligament in 6 (17%) limbs on right side, 8(23%) limbs on left side. CONCLUSIONS: The knowledge of site and level of origin of Profundafemoris artery helps in avoiding the formation of iatrogenic femoral arteriovenous stula (0.1-1.5%) while performing femoral artery puncture during femoral puncture, cardiac catheterisation and radiological procedures