Planning and optimising DIEP flaps with virtual surgery: the Navarra experience

Methods to improve operative outcomes in deep inferior epigastric artery perforator flap surgery have previously focussed on operative technique and postoperative-course modification. Recently, preoperative imaging has become capable of mapping the entire course of perforating vessels, including those vessels as small as 0.3 mm, enabling 'virtual surgery' to be performed preoperatively. This has been shown to facilitate faster and safer surgery. The recent 'Navarra' meeting classified current imaging modalities and discussed the current status of imaging modalities for this role. This article discusses the current expectations and optimal techniques for achieving these outcomes through the available imaging modalities: Doppler ultrasound, colour Doppler ( duplex) ultrasound, computed tomography angiography (CTA) and magnetic resonance angiography (MRA). Features of imaging that are of importance to the surgeon are explored, and a consensus statement has been developed that describes exactly what the current imaging modalities should aim to deliver to the surgeon prior to operating, as well as the benefits and pitfalls of each of these modalities. The techniques described herein permit the radiologist and the surgeon to perform virtual surgery together, preoperatively.</p

Autologous microsurgical breast reconstruction and coronary artery bypass grafting: an anatomical study and clinical implications

OBJECTIVE: To identify possible avenues of sparing the internal mammary artery (IMA) for coronary artery bypass grafting (CABG) in women undergoing autologous breast reconstruction with deep inferior epigastric artery perforator (DIEP) flaps. BACKGROUND: Optimal autologous reconstruction of the breast and coronary artery bypass grafting (CABG) are often mutually exclusive as they both require utilisation of the IMA as the preferred arterial conduit. Given the prevalence of both breast cancer and coronary artery disease, this is an important issue for women's health as women with DIEP flap reconstructions and women at increased risk of developing coronary artery disease are potentially restricted from receiving this reconstructive option should the other condition arise. METHODS: The largest clinical and cadaveric anatomical study (n=315) to date was performed, investigating four solutions to this predicament by correlating the precise requirements of breast reconstruction and CABG against the anatomical features of the in situ IMAs. This information was supplemented by a thorough literature review. RESULTS: Minimum lengths of the left and right IMA needed for grafting to the left-anterior descending artery are 160.08 and 177.80 mm, respectively. Based on anatomical findings, the suitable options for anastomosis to each intercostals space are offered. In addition, 87-91% of patients have IMA perforator vessels to which DIEP flaps can be anastomosed in the first- and second-intercostal spaces. CONCLUSION: We outline five methods of preserving the IMA for future CABG: (1) lowering the level of DIEP flaps to the fourth- and fifth-intercostals spaces, (2) using the DIEP pedicle as an intermediary for CABG, (3) using IMA perforators to spare the IMA proper, (4) using and end-to-side anastomosis between the DIEP pedicle and IMA and (5) anastomosis of DIEP flaps using retrograde flow from the distal IMA. With careful patient selection, we hypothesize using the IMA for autologous breast reconstruction need not be an absolute contraindication for future CABG

Procedural Impact of Advanced Calcific Plaque Modification Devices Within Percutaneous Revascularization of Chronic Total Occlusions.

Background: Significant calcifications within a coronary chronic total occlusion (CTO) increase procedural complexity and the risk for complications. Expert consensus documents recommend the use of advanced calcific plaque modification devices (ACPMDs) for calcified CTO percutaneous coronary intervention (PCI), whereas data on their procedural impact are limited. Objectives: The aim of this study was to describe trends, settings, and outcomes of PCI of severely calcified CTO performed with and without ACPMDs. Methods: Data from 15,329 CTO PCIs enrolled in the ERCTO (European Registry of Chronic Total Occlusion) between 2021 and 2023 were analyzed. On the basis of the presence of severe calcifications within the CTO, the study population was divided into 2 groups: nonsevere (n = 12,289) and severe (n = 3,040) calcium. Then, the severe group was divided into non-ACPMD (n = 2,253) and ACPMD (n = 787), according to the use of ACPMDs. Results: Compared with the non-ACPMD group, the ACPMD group had higher rates of antegrade wiring (77.9% vs 49.2%; P &lt; 0.001) and technical success (97.6% vs 79.1%; P = 0.001) and lower rates of periprocedural and in-hospital major adverse cardiac and cerebrovascular events (MACCE) (1.8% vs 3.5%; P = 0.001). A severe amount of calcium was independently associated with technical failure (OR: 3.13; 95% CI: 2.43-4.09; P &lt; 0.001) but not with MACCE (OR: 0.88; 95% CI: 0.58-1.35; P = 0.15). Furthermore, extraplaque crossing was independently associated with MACCE (antegrade dissection and re-entry without retrograde contribution: OR: 3.12; 95% CI: 1.79-4.20; P &lt; 0.001; antegrade dissection and re-entry with retrograde contribution: OR: 3.12; 95% CI: 1.67-4.11; P = 0.049; retrograde dissection and re-entry: OR: 1.90; 95% CI: 1.25-2.86; P = 0.002). Conclusions: Applying ACPMDs in severely calcified CTO to PCI was associated with higher technical success and lower MACCE rates. The presence of severe coronary calcification on coronary angiography was a marker of clinical and procedural complexity and was associated with technical failure but not with MACCE

ESPRAS Survey on Continuing Education in Plastic, Reconstructive and Aesthetic Surgery in Europe

Background Specialty training in plastic, reconstructive and aesthetic surgery is a prerequisite for safe and effective provision of care. The aim of this study was to assess and portray similarities and differences in the continuing education and specialization in plastic surgery in Europe. Material and Methods A detailed questionnaire was designed and distributed utilizing an online survey administration software. Questions addressed core items regarding continuing education and specialization in plastic surgery in Europe. Participants were addressed directly via the European Leadership Forum (ELF) of the European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS). All participants had detailed knowledge of the organization and management of plastic surgical training in their respective country. Results The survey was completed by 29 participants from 23 European countries. During specialization, plastic surgeons in Europe are trained in advanced tissue transfer and repair and aesthetic principles in all parts of the human body and within several subspecialties. Moreover, rotations in intensive as well as emergency care are compulsory in most European countries. Board certification is only provided for surgeons who have had multiple years of training regulated by a national board, who provide evidence of individually performed operative procedures in several anatomical regions and subspecialties, and who pass a final oral and/or written examination. Conclusion Board certified plastic surgeons meet the highest degree of qualification, are trained in all parts of the body and in the management of complications. The standard of continuing education and qualification of European plastic surgeons is high, providing an excellent level of plastic surgical care throughout Europe

Procedural Impact of Advanced Calcific Plaque Modification Devices Within Percutaneous Revascularization of Chronic Total Occlusions

Background: Significant calcifications within a coronary chronic total occlusion (CTO) increase procedural complexity and the risk for complications. Expert consensus documents recommend the use of advanced calcific plaque modification devices (ACPMDs) for calcified CTO percutaneous coronary intervention (PCI), whereas data on their procedural impact are limited. Objectives: The aim of this study was to describe trends, settings, and outcomes of PCI of severely calcified CTO performed with and without ACPMDs. Methods: Data from 15,329 CTO PCIs enrolled in the ERCTO (European Registry of Chronic Total Occlusion) between 2021 and 2023 were analyzed. On the basis of the presence of severe calcifications within the CTO, the study population was divided into 2 groups: nonsevere (n = 12,289) and severe (n = 3,040) calcium. Then, the severe group was divided into non-ACPMD (n = 2,253) and ACPMD (n = 787), according to the use of ACPMDs. Results: Compared with the non-ACPMD group, the ACPMD group had higher rates of antegrade wiring (77.9% vs 49.2%; P &lt; 0.001) and technical success (97.6% vs 79.1%; P = 0.001) and lower rates of periprocedural and in-hospital major adverse cardiac and cerebrovascular events (MACCE) (1.8% vs 3.5%; P = 0.001). A severe amount of calcium was independently associated with technical failure (OR: 3.13; 95% CI: 2.43-4.09; P &lt; 0.001) but not with MACCE (OR: 0.88; 95% CI: 0.58-1.35; P = 0.15). Furthermore, extraplaque crossing was independently associated with MACCE (antegrade dissection and re-entry without retrograde contribution: OR: 3.12; 95% CI: 1.79-4.20; P &lt; 0.001; antegrade dissection and re-entry with retrograde contribution: OR: 3.12; 95% CI: 1.67-4.11; P = 0.049; retrograde dissection and re-entry: OR: 1.90; 95% CI: 1.25-2.86; P = 0.002). Conclusions: Applying ACPMDs in severely calcified CTO to PCI was associated with higher technical success and lower MACCE rates. The presence of severe coronary calcification on coronary angiography was a marker of clinical and procedural complexity and was associated with technical failure but not with MACCE.</p

Common Peptides Study of Aminoacyl-tRNA Synthetases

Aminoacyl tRNA synthetases (aaRSs) constitute an essential enzyme super-family, providing fidelity of the translation process of mRNA to proteins in living cells. They are common to all kingdoms and are of utmost importance to all organisms. It is thus of great interest to understand the evolutionary relationships among them and underline signature motifs defining their common domains.We utilized the Common Peptides (CPs) framework, based on extracted deterministic motifs from all aaRSs, to study family-specific properties. We identified novel aaRS–class related signatures that may supplement the current classification methods and provide a basis for identifying functional regions specific to each aaRS class. We exploited the space spanned by the CPs in order to identify similarities between aaRS families that are not observed using sequence alignment methods, identifying different inter-aaRS associations across different kingdom of life. We explored the evolutionary history of the aaRS families and evolutionary origins of the mitochondrial aaRSs. Lastly, we showed that prevalent CPs significantly overlap known catalytic and binding sites, suggesting that they have meaningful functional roles, as well as identifying a motif shared between aaRSs and a the Biotin-[acetyl-CoA carboxylase] synthetase (birA) enzyme overlapping binding sites in both families.The study presents the multitude of ways to exploit the CP framework in order to extract meaningful patterns from the aaRS super-family. Specific CPs, discovered in this study, may play important roles in the functionality of these enzymes. We explored the evolutionary patterns in each aaRS family and tracked remote evolutionary links between these families

International lower limb collaborative (INTELLECT) study: a multicentre, international retrospective audit of lower extremity open fractures

Trauma remains a major cause of mortality and disability across the world1, with a higher burden in developing nations2. Open lower extremity injuries are devastating events from a physical3, mental health4, and socioeconomic5 standpoint. The potential sequelae, including risk of chronic infection and amputation, can lead to delayed recovery and major disability6. This international study aimed to describe global disparities, timely intervention, guideline-directed care, and economic aspects of open lower limb injuries