The surgical treatment of the rare extracranial carotid artery aneurysm can lead to significant thromboembolic events in 4.4% of cases. Intraoperative monitoring has helped detect hypoperfusion and probable ischemic events, but this is not widely available in resource-limited hospitals in the Philippines. This case highlights the use of a portable standard 21-channel EEG machine for intraoperative monitoring in a tertiary government hospital. In addition, it highlights a conception of a protocol for the intraoperative electroencephalogram monitoring of carotid endoaneurysmorrhaphy procedures in a resource-limited setting. During the aneurysmorrhaphy procedure, the authors collaborated with the surgeons and the anesthesiologists to provide feedback about EEG changes during the operation. After a pre-induction baseline was recorded, continuous EEG monitoring was performed until the patient emerged from anesthesia. Mild EEG changes, attributed to relative hypotension, were observed during the procedure. These episodes were responsive to BP augmentation. There were no EEG changes observed during carotid cross-clamping. Shunting was not recommended to the surgical team. No new neurologic deficits were documented postoperatively and on follow-up after six months. This paper illustrates how an intraoperative team was formed, and intraoperative EEG was utilized for a complex carotid endoaneurysmorrhaphy for a patient with ECAA in a tertiary government hospital in the Philippines.

Objective: The varicocoele exist in approximately 35-40% of primary male factor infertility while two to 10 percent of cases presents with pain.1 Most surgeons favor subinguinal microscopic varicocoelectomy because it offers superior improvement in semen parameters and reproductive outcome with the least complication rate. This study aimed to show an innovative surgical technique in the management of men with varicoceles. Methods: Subinguinal varicocelectomies were performed by a single surgeon on all patients starting with a standard cystoscope stabilized by a customized mechanical holding system attached to the operating bed. All the presumed vascular channels, vas deferens and lymphatics were isolated and marked with vascular loops and surgical ties. After all the presumed vessels were tagged, the standard operating microscope was brought to the operative field and full microsurgical dissection was carried out. Results: Ten varicocelectomies were performed on six men with a mean age of 30.5 years. 13 arteries, 84 veins, and 20 lymphatics were identified by the cystoscope while 18 arteries, 93 veins, and 29 lymphatics were identified by the standard operating microscope. Comparing the two modalities, 72%, 90%, and 69% of the arteries, veins, and lymphatics, respectively, were correctly identified by the cystoscope when compared to the latter. Conclusion Subinguinal varicocelectomy using a standard cystoscope could be offered as an alternative surgical approach in men with varicoceles as it can identify veins comparable with that of the standard operating microscope. In addition, a standard cystoscope can also identify, to some degree, lymphatics and arteries during surgical dissection. This innovative surgical technique can serve as a valuable option in the treatment of men with varicoceles.
Cystoscopes ; Veins ; Arteries

Protein S deficiency causing arterial ischemic stroke during pregnancy is uncommon. Delay or omission of treatment with perfusion therapies may worsen outcomes for both the mother and the fetus. In this paper, we report a case of an early pregnant woman with protein S deficiency and multiple history of chronic cerebrovascular disease who underwent successful thrombolysis and mechanical thrombectomy. The patient is a 35-year-old woman, eight weeks pregnant, with a history of protein S deficiency and chronic cerebrovascular disease, presenting with rightsided weakness and aphasia. Initial National Institutes of Health Stroke Scale was 10 with cranial magnetic resonance imaging findings of acute infarcts on the left caudate, lentiform nucleus, insula, and frontal lobe with a large vessel occlusion on the proximal M1 segment of the left middle cerebral artery. Intravenous thrombolysis and mechanical thrombectomy were performed with complete recanalization. The patient improved and delivered without any complications after 8 months. Protein S deficiency can contribute to arterial thrombosis including ischemic stroke. Arterial ischemic stroke and large vessel occlusion can cause significant disability if not treated appropriately. Reperfusion therapies in pregnant women show favorable outcomes and should be performed if the benefits outweigh the risks.

Heart failure (HF) is a major cause of significant morbidity, mortality, and hospitalization worldwide including the Philippines. Congenitally corrected transposition of the great arteries (C-TGA) occurs when the right atrium enters the morphological left ventricle which gives rise to the pulmonary artery and the left atrium communicates with the right ventricle which gives rise to the aorta. Heart failure can occur in C-TGA especially if associated with other heart defects. Ideal management is anatomic correction via surgery to prevent or address heart failure. Peritoneal dialysis has been used as a therapeutic intervention for patients with refractory heart failure and kidney injury with or without kidney failure due to its gentler fluid removal compared to conventional ultrafiltration resulting in less myocardial stunning and neurohormonal activation. We present the case of a patient with heart failure who started on peritoneal dialysis (PD) as an adjunct therapy for fluid management after failing to satisfactorily achieve volume control with diuretics. The patient is a 56-year-old man with C-TGA admitted for decompensated heart failure. He was initially treated with intravenous diuretics on the first admission but was readmitted after 3 months for decompensation this time with borderline low blood pressure making diuresis difficult. The patient was given loop diuretics, tolvaptan, and angiotensin receptor neprilysin inhibitor (ARNI) but still with decreasing trends in urine output and inadequate symptom control. PD was initiated before discharge with subsequent improvement in heart failure symptoms. The patient was on regular follow-up for PD maintenance and titration of heart failure medication. In this case report, we have shown how PD can be an effective adjunct to guideline-directed medical therapy in patients with severely symptomatic heart failure who have an unstable hemodynamic status and for which volume management cannot be satisfactorily achieved with diuretics.
peritoneal dialysis ; heart failure ; congenital heart disease ; congenitally corrected transposition of the great arteries ; diuresis ; ultrafiltration

Objective: To explore the safety and efficacy of transcatheter aortic valve replacement (TAVR) using the "All in One" single-artery/vessel technique. Methods: This is a retrospective study. A total of 30 consecutive patients underwent TAVR using the single artery/vascular technique in Beijing Anzhen Hospital from August to December 2021 were included. Baseline clinical data, operative situation, postoperative outcomes, and incidence of adverse events during hospitalization and at one month post TAVR were analyzed. Results: Mean age was (72.6±9.7) years, 16 were male patients, STS score was (4.73±3.12)%. Four patients were diagnosed as isolated aortic regurgitation (all with tricuspid aortic valves), and 26 patients were diagnosed as aortic stenosis (AS), 10 of whom with tricuspid aortic valves and 16 of whom with bicuspid aortic valves. The single-vessel technique was applied in 3 aortic stenosis cases; the single-artery technique was applied in 27 cases. Echocardiography was performed immediately after procedure and results showed no or trace perivalvular leak in 27 cases and small perivalvular leak in 3 cases; the mean aortic transvalvular gradient of 26 AS patients decreased from (50.4±16.0) mmHg (1 mmHg=0.133 kPa) to (9.4±3.2) mmHg (P<0.001). The procedure time was (64.8±18.9) min. There were no intraoperative death, valve displacement, conversion to surgery, coronary artery occlusion in all 30 patients. There were no major cardiac adverse events such as myocardial infarction or stroke occurred during hospitalization or at follow-up. One-month follow-up echocardiography indicated prosthesis works well. The symptoms were significantly alleviated, and the Kansas City Cardiomyopathy Score (KCCQ score) of all patients increased from 48.1±18.4 to 73.5±17.6 (P<0.001). Conclusions: TAVR using the single artery/vessel technique is safe and feasible. This technique is related to reduced access complications and worthy of wide application.
Humans ; Male ; Middle Aged ; Aged ; Aged, 80 and over ; Female ; Transcatheter Aortic Valve Replacement ; Retrospective Studies ; Arteries ; Aorta ; Aortic Valve Stenosis/surgery*

Objective: To investigate the relationship between obstructive sleep apnea (OSA), apnea hypopnea index (AHI) and vascular injury in hypertensive patients. Methods: This cross-sectional study enrolled patients admitted to the Hypertension Department of TEDA International Cardiovascular Hospital from April 2020 to April 2023, who finished portable sleep monitoring. Sleep monitoring indicators, flow-mediated vasodilation (FMD), carotid artery ultrasound, carotid intima-media thickness, cervical and femoral pulse wave conduction velocity (cfPWV), brachial and ankle pulse wave conduction velocity (baPWV) were analyzed. OSA was classified into mild (5 times/h≤AHI<15 times/h), moderate (15≤AHI<30 times/h), and severe (AHI≥30 times/h) based on AHI levels. FMD<6.0% was defined as vascular endothelial injury, and cfPWV>10 m/s and/or baPWV>18 m/s was defined as arterial stiffness. Multivariate logistic regression analysis was used to explore the correlation between AHI, OSA severity and vascular injury, and subgroup analysis was performed in young (age≤45 years) and middle-to-old patients (age>45 years). Sensitivity analysis was performed by excluding patients with diabetes, cerebrovascular disease and coronary heart disease. The correlation between AHI and vascular injury index was analyzed by restricted cubic spline. Results: A total of 555 adult hypertensive patients were included, the mean age was (39.7±9.2) years, 422 were males (76.0%), and the prevalence of OSA was 66.7% (370/555). Multivariate logistic regression analysis showed that moderate OSA (OR=2.83, P=0.019) and severe OSA (OR=3.40, P=0.016) were positively correlated with vascular endothelial injury after adjusting for age, sex, body mass index and mean arterial pressure. Subgroup analysis showed that log AHI (OR=1.99, P=0.035), moderate OSA (OR=4.83, P=0.010) and severe OSA (OR=4.64, P=0.015) were associated with vascular endothelial injury in young hypertensive patients. The results of sensitivity analysis were similar to the above results. The results of restricted cubic spline analysis showed that AHI was correlated with FMD (P=0.022), and the slope of the curve was the largest when AHI was between 0 and 10 times/h. There was no correlation between log AHI and OSA severity and carotid intima-media thickening and arterial stiffness (all P<0.05). Conclusions: OSA is associated with vascular endothelial injury in hypertensive patients, especially in young patients.
Male ; Humans ; Adult ; Middle Aged ; Female ; Carotid Intima-Media Thickness ; Vascular System Injuries ; Cross-Sectional Studies ; Hypertension/complications* ; Sleep Apnea, Obstructive/complications* ; Carotid Arteries ; Vascular Stiffness

OBJECTIVE: To explore the feasibility of using indocyanine green angiography in mapping the superficial temporal vessels and assisting design and harvesting of the superficial temporal artery based forehead flap. METHODS: A clinical data of 14 patients with facial soft tissue defects repaired with superficial temporal artery based forehead flaps between October 2015 and November 2022 was retrospectively analyzed. There were 9 males and 5 females with a median age of 9.5 years (range, 3-38 years). The forehead flaps were used to reconstruct facial soft tissue defects following excision of facial scar (8 cases) or congenital melanocyte nevus (6 cases). The size of defects ranged from 3 cm×2 cm to 24 cm×9 cm. Before operation, the indocyanine green angiography was used to map the superficial temporal artery and vein, and to analyze the relationship of the arteries and veins. The forehead flaps with unilateral superficial temporal fascia as the pedicle was transferred to repair the small facial defect in 2 cases. The facial pedicle contained the frontal branch of the superficial temporal artery and 2 cm of the superficial temporal fascia around the vessel, and the tiny accompanying vein of the frontal branch of the superficial temporal artery was used as the outflow of the flap. The forehead flaps with the skin pedicle including bilateral or unilateral superficial temporal fascia and the overlying skin was pre-expanded and transferred to repair the large facial defect in 12 cases. The skin pedicle contained the frontal branch of superficial temporal artery and one of main branches of superficial temporal vein. Among the 12 cases, the frontal branch of superficial temporal vein was used as the outflow in 4 cases, and the parietal branch was used as the outflow in 8 cases. The size of the flaps ranged from 3 cm×2 cm to 30 cm×13 cm. The skin pedicles were divided at 3 weeks after the flap transfer. RESULTS: Indocyanine green angiography could clearly showed the course and branching of the superficial temporal artery and vein. Individual differences existed in the location where the frontal branch of the superficial temporal artery entered the forehead. The superficial temporal vein had great variability and did not follow the artery. One patient had expander-related complication, which resulted in 3-cm flap necrosis. The necrotic tissue was debrided and repaired with skin grafting. The other flaps totally survived and the incisions healed by first intention. All patients were followed up 2-24 months, with a median of 11.5 months. The color, texture, and thickness of the flaps matched well with those of recipient sites. Hypertrophic scar was not observed in recipient or donor site. All patients were satisfied with the reconstructive outcomes. CONCLUSION Indocyanine green angiography can clearly visualize the course and the branches of the superficial temporal arteries and veins, which can help surgeons understand the position, distribution, and concomitant relationship of the superficial temporal vessels, and make a rational surgical plan of the forehead flap.
Male ; Female ; Humans ; Child, Preschool ; Child ; Adolescent ; Young Adult ; Adult ; Temporal Arteries/surgery* ; Indocyanine Green ; Forehead/surgery* ; Retrospective Studies ; Skin Transplantation ; Angiography ; Soft Tissue Injuries/surgery* ; Perforator Flap/blood supply* ; Treatment Outcome

OBJECTIVE: To investigate the feasibility and effectiveness of bilateral facial perforator artery flap in repairing large area defect in middle and lower part of nose. METHODS: The clinical data of 18 patients with large area defect in middle and lower part of nose repaired by bilateral facial perforator artery flap between January 2019 and December 2022 were retrospectively analyzed. Among them, there were 13 males and 5 females, the age ranged from 43 to 81 years, with an average of 63 years. There were 3 cases of nasal trauma, 4 cases of basal cell carcinoma, 8 cases of squamous cell carcinoma, 1 case of lymphoma, and 2 cases of large area solar keratosis. The size of the defect ranged from 3.0 cm×3.0 cm to 4.5 cm×4.0 cm; the size of unilateral flap ranged from 3.0 cm×1.3 cm to 3.5 cm×2.0 cm, and the size of bilateral flaps ranged from 3.3 cm×2.6 cm to 4.5 cm×4.0 cm. RESULTS: One patient developed skin flap necrosis after operation, and a frontal skin flap was used to repair the wound; 1 case gradually improved after removing some sutures due to venous congestion in the skin flap, and the wound healing was delayed after dressing change; the remaining 16 cases of bilateral facial perforator artery flaps survived well and all wounds healed by first intention, without any "cat ear" malformation. All 18 patients had first intention healing in the donor area, leaving linear scars without obvious scar hyperplasia, and no facial organ displacement. All patients were followed up 3-12 months, with an average of 6 months. Due to the appropriate thickness of the flap, none of the 18 patients underwent secondary flap thinning surgery. All flaps had good blood circulation, similar texture and color to surrounding tissues, symmetrical bilateral nasolabial sulcus, and high patient satisfaction. CONCLUSION The bilateral facial perforator artery flaps for repairing large area defect in middle and lower part of nose can achieve good appearance and function, and the operation is relatively simple, with high patient satisfaction.
Male ; Female ; Humans ; Adult ; Middle Aged ; Aged ; Aged, 80 and over ; Plastic Surgery Procedures ; Skin Transplantation ; Retrospective Studies ; Soft Tissue Injuries/surgery* ; Perforator Flap/blood supply* ; Arteries/surgery* ; Cicatrix/surgery* ; Treatment Outcome ; Skin Neoplasms/surgery*

Humans ; Coronary Artery Disease ; Coronary Artery Bypass ; Arteries

Humans ; Otosclerosis/surgery* ; Stapes ; Stapes Surgery/adverse effects* ; Arteries