Preoperative Doppler Ultrasonography Allen Test for Radial Forearm Free Flap in Oral Cancer Reconstruction: Implications in Clinical Practice

The Radial Forearm Free Flap (RFFF) is one of the most widely used microsurgical flaps for intraoral reconstruction. Although the Clinical Allen Test (CAT) is the most widely used preoperative diagnostic method with which to study the distal patency of the hand prior to the use of RFFF, several authors have reported potentially preventable serious vascular complications. This study included 87 consecutive patients with cancer of the oral cavity and RFFF as the flap of choice who were treated between 2010 and 2020, and compares the results of the Clinical Allen Test (CAT), the Doppler Allen Test (DAT) and the Surgical Allen Test (SAT). The preoperative vascular study found vascular abnormalities severe enough for the surgical team to change the preoperative flap of choice in 39% of patients. The Kappa index showed a weak concordance between the CAT and DAT. The study reflected a total concordance in the preoperative results of the Doppler study and the intraoperative results of the SAT. Due to its excellent agreement with SAT, the DAT would be the preoperative test of choice in patients who are candidates for RFFF. This study of vascular mapping tests with Doppler is intended to inform therapeutic decisions and present methods to gain information that cannot be obtained by physical examination alone.

Observation of the Absence of Ulnar Artery in a Patient Planned to Free Dorsoulnar Artery Perforator Flap for Finger Defect: Is Preoperative Doppler evaluation of Perforator Alone Sufficient?

Background Volar finger defects where critical structures exposed are always challenging for plastic surgeons. In these types of defects, local flaps, cross finger flaps, abdominal flaps, and free flaps are used. Free dorsoulnar artery perforator (DUAP) flaps and superficial palmar branch of radial artery (SPBRA) flaps are also used. In this case, we present a patient who was scheduled to receive a DUAP flap to address defect on the second finger of right hand; however, we repaired the defect with a SPBRA flap because intraoperative absence of the ulnar artery was observed. Materials and Methods A 34-year-old male patient was admitted with a wound that exposed the tendon and neurovascular bundle on the volar side of the second finger of the right hand. A free DUAP flap was planned for the patient. A perforator was detected during the preoperative Doppler ultrasound examination. While dissecting the perforator, we noted the absence of an ulnar artery proximal to the perforator vessel. The elevated SPBRA flap from same extremity and the defect were closed. Results Postoperative computer tomography showed an absence of the ulnar artery distal to the right antecubital region. No complications were seen in the donor and recipient areas. Long-term motor movements were natural, and the patient's quality of life was good. Conclusion Determining the perforator site using Doppler alone may not be sufficient in preoperative evaluation of patients scheduled to receive DUAP flaps. Performing an Allen test and using advanced imaging methods can prevent surgeons from encountering a bad surprise.

A preoperative modified Allen test result may be associated with long term mortality after hemodialysis access construction

Background: The modified Allen test (MAT) is a simple bedside method determining collateral hand circulation prior to hemodialysis (HD) access surgery. Hand ischemia as reflected by low systolic finger pressures ( Pdig) is associated with high mortality rates in severe kidney disease (CKD) patients. Aim of the present study was to assess a possible relation between absolute finger pressure drop (∂ Pdig) during a preoperative MAT and mortality after a first HD access construction. Methods: Pdig (systolic pressure, mmHg) was measured using digital plethysmography following compression of radial and ulnar arteries in CKD patients just before access surgery between January 2009 and December 2018 in one center. The greatest ∂ Pdig of both index fingers was used for analysis. Cardiovascular and overall mortality were assessed during the following 4 years using the ERA-EDTA classification system (codes 11, 14–16, 18, 22–26, 29). Cox regression analysis determined possible associations between ∂ Pdig and mortality. Results: Complete data sets were available in 108 patients (male n = 71; age 70 years ±12; mean follow up (FU) 1.6 years ±0.1; FU index 99% ±1). Median ∂ Pdig was 31 mmHg (range 0–167 mmHg). Patients having cardiovascular disease (CV+) demonstrated higher ∂ Pdig values (CV+ 44 ± 5 mmHg vs CV− 29 ± 3 mmHg, p = 0.012). A total of 26 patients (24%) died during FU (CV+ death, n = 16; 62%). For each 10 mmHg ∂ Pdig increase, overall mortality increased by 10%, and CV+ mortality by 15% (overall mortality: HR 1.10 [1.01–1.22], p = 0.048; CV+ mortality: 1.15 [1.03–1.29], p = 0.017). Following correction for age, ∂ Pdig remained associated with CV+ mortality (HR 1.13 [1.00–1.26], p = 0.043). Conclusions: A large drop in systolic finger pressure during a preoperative MAT is related to mortality after primary HD access surgery. The role of this potential novel risk parameter requires confirmation in a larger population.

HRV‐Monitoring im Rahmen eines vierwöchigen High‐Intensity Intervalltrainings

EINLEITUNG. Das Monitoring von Belastungs‐ und Erholungsreaktionen im Sport gilt mittlerweile als zentralesInstrument im Prozess der Optimierung und Individualisierung von Trainingsmaßnahmen. Die Messungder Herzfrequenz (HR) ‐variabilität (HRV) stellt hier ein vielversprechendes Monitoringtool dar,welches einen Einblick in Aktivität und Regulationsmechanismen des kardial‐autonomen Nervensystems(ANS) liefert. Ziel der Studie ist die Evaluation eines HRV‐Monitorings im Rahmen eines vierwöchigenHigh‐Intensity Intervalltrainings (HIT) hinsichtlich der Fähigkeit Belastungs‐ und Erholungsreaktionensowie Leistungsveränderungen abzubilden.METHODIK. 12 trainierte Probanden aus intermittierenden Sportarten absolvierten einen 4‐wöchigen,periodisierten HIT‐Zyklus mit jeweils 3 Trainingseinheiten pro Woche. Die maximale und submaximaleLeistungsfähigkeit wurde mittels Stufentests auf dem Laufband vor (Baseline) sowie zwei (Post 1) undneun Tage (Post 2) nach der Interventionsphase ermittelt. Der allgemeine Erholungsstatus (KEB) wurdean allen Test‐ und Trainingstagen erfragt. Begleitend, sowie zwei Wochen vor und nach der Intervention,wurden täglich 6‐minütige HRV‐Ruhemessungen nach dem Aufstehen durchgeführt und anschließendmittels gleitendem 7 Tage‐Mittelwert analysiert.ERGEBNISSE. Das Training löste moderate bis starke (Cohen’s d = ‐1,12 bis ‐1,25) Ermüdungserscheinungen(KEB) in den Interventionswochen 1 und 3 (likely bis most likely) aus. Die maximale Leistungsfähigkeitzeigte klare Verbesserungen (d = 0,20 bis 0,41) an Post 1 und Post 2 (likely bis most likely), wobei diesubmaximale Leistungsfähigkeit tendenziell (possibly) an Post 2 gering (d = 0,21 bis 0,23) erhöht war. DerHRV‐Parameter Ln rMSSD/RR war an Post 2 gering (d = ‐0,40) verringert (likely). Die drei Einzelfallanalysenzeigten erheblich divergierende ANS‐Reaktionen bei den betrachteten Athleten, welche sich vergleichbarüberdurchschnittlich in ihrer submaximalen und maximalen Leistungsfähigkeit verbesserten.SCHLUSSFOLGERUNG. Ein HRV‐Monitoring auf Grundlage täglicher Ruhemessungen und gleitender 7 Tage‐Mittelwertsbildung ist auf Gruppenebene nicht in der Lage die beobachteten Belastungs‐ und Erholungsreaktionenoder die Leistungsverbesserungen abzubilden. Im Rahmen von Einzelfallanalysenscheint die HRV potenziell nützliche Informationen hinsichtlich individueller Adaptationsverläufen liefernzu können, welche möglicherweise eine Individualisierung und Optimierung von Trainingsplanungund ‐steuerung ermöglichen. Dennoch stehen Aufwand und Nutzen, sowohl auf Gruppen‐ als auch aufEinzelfallebene, in einem deutlichen Defizitverhältnis. Ein HRV‐Monitoring ist derzeit unter Anwendungder etablierten Methoden in vergleichbaren Settings nicht empfehlenswert.