Pulmonary AVM Embolization Jelena Ivanis1; Andrew Ding1; Dennis Barbon1; Fabian Laage-Gaupp, MD2; Jeffrey Pollak, MD2 1Frank H. Netter, MD School of Medicine at Quinnipiac University 2Yale School of Medicine
Pulmonary arteriovenous malformations (PAVMs) are rare fistulous connections between pulmonary arteries and veins that, as in this case, are commonly associated with hereditary hemorrhagic telangiectasia (HHT). Embolotherapy, the mainstay of treatment for PAVMs, is a procedure in which the feeding arteries of a malformation are endovascularly occluded under fluoroscopic guidance. Effective and well-tolerated, embolotherapy has been shown to decrease right-to-left shunting following treatment and decrease risks of paradoxical embolization and lung hemorrhage and to improve pulmonary gas exchange and lung function. Patients are selected for treatment according to clinical suspicion for the presence of a PAVM and feeding artery diameter. The occlusion of PAVMs with arteries that exceed 2–3 mm in diameter is recommended.
Diagnostic contrast-enhanced pulmonary angiography is performed via injection of contrast through a percutaneous catheter to characterize and confirm PAVMs suitable for embolization. Lesions are then treated by catheter-directed placement of embolic material— vascular plugs in this case—into the feeding artery, terminating blood flow to the area of the lesion. Although multiple PAVMs may be embolized during a single session, in patients with HHT, who may present with large numbers of PAVMs, treatment is limited by maximum contrast dosage, and additional sessions may be performed if PAVMs remain perfused.
Heated Intraperitoneal Chemotherapy (HIPEC) coupled with cytoreduction is increasingly being used to treat isolated peritoneal dissemination of intra-abdominal malignancies. Cytoreductive surgery (CRS) is initially performed using either a conventional open or laparoscopic approach. CRS includes removal of the main tumor, excision of any other visible tumors, peritonectomy, omentectomy, and intestinal resections, if necessary. Following CRS, a chemotherapeutic solution is administered at a temperature of 40 to 41.5 °C. Infusing chemotherapy immediately following CRS facilitates a uniform distribution of the solution throughout the entire peritoneal cavity. This strategy prevents localized spread that may arise from postoperative adhesion formation, ensuring that peritoneal surfaces are exposed to a concentrated chemotherapy dose while minimizing systemic toxicity.
Epidural analgesia provides effective pain management and is generally well tolerated by patients undergoing CRS in conjunction with HIPEC. This video provides a comprehensive step-by-step demonstration of the entire procedure. The epidural injection involves the delivery of anesthetic solution to the epidural space surrounding the spinal cord within the vertebral column, inducing anesthesia in the spinal segments below the site of catheter placement.
Portal Placement for Hip Arthroscopy Steven D. Sartore1; Scott D. Martin, MD2 1Lake Erie College of Osteopathic Medicine 2Brigham and Women’s/Mass General Health Care Center
Hip arthroscopy is a well-established technique that has become a mainstay in the repair of bony and ligamentous injuries when conservative methods fail to return adequate joint mobility and function. The technique has both diagnostic and therapeutic utility and its use as a minimally invasive orthopedic surgery continues to advance. Several studies have suggested that arthroscopic surgical management has more favorable outcomes in certain circumstances when compared to hip-specific conservative measures.
The approach to establishing adequate sites for portal placement is dependent upon recognizing the pertinent anatomy of the surgical site. At the same time, the operator must be mindful of the desired views once access to the joint space has been obtained. Proper visualization of the desired joint region is critical to reducing the conversion of THAs into inherently riskier total joint procedures. Additionally, the neurovascular landscape of the groin presents technical challenges with the procedural approach, which requires significant skill to avoid vital structures in the area. Acetabular labral tears are frequently repaired with this type of operative management as techniques and approaches become more refined. Here, the authors present the case of a 24-year-old woman who is undergoing an arthroscopic anterior labral repair, highlighting both the anatomical landmarks and the access points for portal placement used in the procedure.
Over the past decade, laparoscopic donor nephrectomy has gradually replaced the conventional open approach and has become the standard of care in living donor kidney transplantations. Compared to open nephrectomy, laparoscopic nephrectomy reduces postoperative pain, shortens the length of hospital stay, and improves the cosmetic outcome. This article illustrates the author’s technique of pure laparoscopic donor nephrectomy.
Intracranial hypertension is a critical concern in traumatic brain injury (TBI), with elevated intracranial pressure (ICP) significantly impacting patient outcomes. ICP monitoring is an essential component in managing patients with various brain pathologies that can lead to dangerously elevated intracranial pressure. In neurosurgical practice, accurate monitoring and timely intervention are critical when dealing with the challenges of intracranial hypertension, and its timely resolution is crucial for preventing severe neurological sequelae and fatal outcomes.
The risk of Infections or hemorrhage of significance associated with ICP devices, which can lead to patient morbidity, usually do not outweigh the benefit of continuous ICP monitoring in TBI. Therefore, these should not deter the decision to monitor ICP.
This video provides step-by-step visual guidance for placing a right frontal Camino bolt to guide optimal patient care. In this clinical case a patient presents without prior opportunity for clinical exam and with reported signs of a cranial hemorrhage, coupled with a right occipital fracture, thereby requiring ICP monitoring to proceed with further neurosurgical care.
Airway injury remains a leading cause of early mortality in patients with trauma. Despite its rarity, direct traumatic airway injury and tracheobronchial injury (TBI) pose significant challenges for emergency clinicians, with an estimated incidence of 0.5–2% among trauma patients. Blunt or penetrating injuries to the head, oropharynx, neck, or upper chest can result in immediate or delayed airway blockage. Trauma can cause airway obstruction by itself or by blood clots, tissue edema, or gastric contents clogging the airway lumen. The added complexity of associated spinal injuries further underscores the need for precise and timely airway assessment.
In the context of trauma patients, a fundamental aspect of care involves prompt airway assessment. The Advanced Trauma Life Support (ATLS) algorithm, a cornerstone in trauma care, outlines a systematic approach focusing on a sequential assessment and management of Airway, Breathing, Circulation, Disability, and Exposure (ABCDE), as part of the initial evaluation of the injured individual. While adapted for battle and disaster environments, the ATLS algorithm consistently emphasizes the timely assessment and treatment of life-threatening airway and breathing issues before shifting focus to circulation problems. The CAB sequence has become more widely embraced in the last ten years, surpassing the airway-breathing-circulation (ABC) model for individuals with serious bleeding injuries. When bleeding is severe or life-threatening, prioritizing control of the bleeding takes precedence over interventions related to airway and breathing․
Orbital floor fractures represent common sequelae of facial trauma that may result in significant functional and aesthetic consequences. This article presents a comprehensive overview of the management of a revision case involving an orbital floor fracture, focusing on complications related to extruded, infected orbital hardware. In addition, common mistakes that involve improper placement of orbital floor implant, poor implant sizing, and lack of adequate implant fixation are discussed.
The featured case involves delayed wound healing and a sino-orbital cutaneous fistula (SOCF) due to infected orbital hardware from a previous orbital floor fracture repair. The discussion centers on preoperative planning, including the choice of surgical approach (transconjunctival with lateral canthotomy) and implant material. Intraoperative neuronavigation was utilized as an adjunctive tool to confirm the position of the newly placed orbital implant. This case provides valuable insight on preventable complications for this procedure, nuances in surgical approach, and uncommon challenges faced by providers who perform operative facial trauma repair.
Surgical Sutures Brandon Buckner, CST, CRCST; Crystal Romero Lamar State College Port Arthur (TX)
Surgical sutures, an essential component of wound closure, are designed to facilitate the healing process. Most surgical or traumatic wounds require approximation of the wound edges of some kind. Typically, this is more often performed using sutures, rather than staples or surgical adhesives. Suturing provides a number of advantages, including reduced rates of wound dehiscence and higher resistance to tension compared to alternative methods of approximation.
Lower lid entropion or inversion is a common involutional inward rotation of the tarsus and eyelid margin. It is caused by a combination of horizontal laxity of the eyelid, attenuation or disinsertion of eyelid retractors, and overriding of preseptal over pretarsal orbicularis muscle fibers. These changes result in the instability of the eyelid with age. The inverted eyelid leads to constant rubbing of eyelashes against the cornea and the globe, causing irritation, foreign body sensation, and in severe cases, corneal erosion, pannus formation, and ulceration. The lateral tarsal strip procedure is aimed at addressing the causes of entropion, thus correcting the eyelid position and improving its function. Upon successful surgical intervention, normal eyelid position and function are restored. Cosmesis of the eyelid also improves. This article will discuss the preoperative assessment of the patient, the preparation, the surgical procedure, and possible complications.
Barbed suture is an increasingly popular type of suture used by surgeons across the world. It is an efficient suture that provides several benefits, including better distributed tensile strength, reduced surrounding inflammatory reaction and local tissue hypoxia, and less foreign body exposure. However, there have been a handful of cases of complications with barbed sutures over the past few decades.
This is the case of a patient who initially underwent an uncomplicated robotic transabdominal preperitoneal ventral hernia repair (rTAPP) and re-presented postoperative day two with a small bowel obstruction. This video shows the operative findings from the return to the operating room with the identification of a barbed suture that had become caught in the mesentery, causing kinking of the bowel.
