Search

Objective: To carry out a 3D vector reconstruction of the nerves of the ventral region of the neck from anatomical sections of the “Korean Visible Human” for educational purposes. Materials and Methods: The anatomical subject was a 33-year-old Korean man who died of leukemia. He was 164cm tall and weighed 55kgs. A cryomacrotome sectioned the frozen body into 5960 sections. Sections numbered 1500 to 2000 were used for this study. A segmentation by manual contouring of each nervous anatomical element of the ventral region of the neck was done using Winsurf version 3.5 software on a laptop PC running Windows 10 equipped with an 8 gigabyte RAM. Results: Our vector 3D model of nerves in the ventral neck region includes the brachial plexuses, vagus nerves, inferior and superior laryngeal nerves, glossopharyngeal nerves, hypoglossal nerves and spinal nerves. This vector model has been integrated into the Diva3d virtual dissection table. It was also uploaded to the Sketchfab website and 3D printed using an ENDER 3 printer. Conclusion: Our 3D reconstruction of the nerves of the ventral region of the neck is an educational tool for learning the nerves of the ventral region of the neck and can also serve as a 3D atlas for simulation purposes for training in therapeutic gestures.

Introduction: Our objective is to highlight the role of the semi-membranosus muscle, which is surprisingly not described in the major books of anatomy, as main thigh pump in the venous return [1]. Material and methods: Latex injection of fresh cadavers followed by anatomical dissection and colored segmentation of the whole venous network of 300 lower limbs, 3D reconstructions by CT venography of 1000 CVD patients are at the basis of this study. Results: The venous arcades of the semi-membranosus muscle constitute a main deep collateral route by-passing the narrowed area of the Hunter’s canal. This anatomical study clearly shows that these venous arcades are regularly connected:(Figure 1) • By their 2 lower branches to the popliteal vein • By their 2 higher branches to the deep femoral vein. Consequently, they constitute a derivative route of the femoral axis, explaining their dilatation in case of stenosis of the Hunter’s canal outlet. Similarly, in a physiological situation, the whole amount of blood ejected by the powerful calf pump through the popliteal vein cannot always reach the femoral vein through the Hunter’s canal: the arcades then play the role of a safety valve. Moreover, the veins of the semi-membranosus muscle constitute a main thigh pump: they push up the blood towards the femoral crossroad at the root of the limb. Discussion and conclusion: The veins of the semi-membranosus should be systematically investigated by USD : their dilatation is the witness of venous outlet syndrome of the Hunter’s canal which is a major cause of femoral vein thrombosis. USD investigation should be systematically carried out at that levels to prevent future deep vein obstruction.

Introduction: The virtual dissection is a new and remarkable learning tool in anatomy. The authors present here a 3D reconstruction of the upper limb from the Visible Korean human slices. [1–4] Materials and methods: The manual segmentation of 1640 anatomical slices was achieved with the SURFdriver® software producing an interactive 3D vectorial model of the left upper limb. Eighty seven anatomical structures were reconstructed as separate 3D objects i.e skin, 31 bones, 29 muscles, 7 tendons, 6 nerves, 5 arteries and 9 veins (ligaments and lymphatics were not reconstructed). Results: They were gathered into a 3D vectorial model of the whole limb and exported in Acrobat(®) 3Dpdf format, producing a true virtual dissection tool: 87 anatomical structures can be individually and interactively manipulated with a touch screen: you can swipe, scroll, zoom, rotate and navigate inside the model as well as remove layers of skin and muscle and take measurements. In addition, 3D labels with the name of each anatomical element are available. Discussion and conclusions: This new computerized virtual dissection table is a simple and powerful learning tool for students. It is also the basis of future simulation tools for surgeon’s training.

Introduction: The aim of this work is to build a new educational tool to better understand venous anatomy of the lower limbs by the help of embryology, Duplex color assessment and 3d modeling by CT venography (CTV) Materials and methods: Pictures of anatomical drawings from the Atlas book of Gillot [1] are illustrated and enhanced by the new imaging techniques of the venous system: 3D venography [2–5] and Color Duplex [6]. A multislice with 64 detectors spiral CT acquisition of the lower limb with contrast injection of the foot produces about 800 slices of the whole limb in 40 seconds. Image processing is done by VRT technique with 2 free softwares running on Macs: Osirix® [www.osirix.com] and Horos® [www.oros.com] Results: Interactive 3d modes are built in real time and movie files of a 360 degres rotation of this 3D model are easily exported to quicktime format. • Easy learning of the superficial venous network, perforators and their connection to the deep system, with the help of embryology • Explanation of the 3 venous compartments of the sural nerve pedicle and hemodynamics of the GSV and SSV termination • Pre-operative surgical assessment of complex /redo varices and congenital vascular malformations in addition to US Duplex and MRI. Discussion and conclusions: The VCT is a powerful tool to investigate the venous system of our patients with chronic venous disease, but it is providing no hemodynamical data, so an additional DUS (color duplex) is mandatory. It makes possible a virtual dissection of the limb, which gives an accurate and interactive 3d map of the whole limb in addition to the landmarks provided by the DUS skin marking before treatment. A lesson of anatomy is proposed, illustrated by a full Interactive use of 3D models. and illustrated by case reports with « virtual dissection » of the patients.

Introduction: The aim of this study is to make an anatomical description of the bony venous perforators (PVs) at the knee level witch are frequently missed during investigation of patients with chronic venous disease. Material and methods: Multiple series of anatomical slices of fresh cadavers injected with green latex and series of CT venographies as well as Duplex color investigations were used to study their precise location and the connections with the venous network of the knee. Results: Anatomically, these PVs are commonly located anteriorly around the patella, and posteriorly in the inter-condylar grove, medially and laterally. Their connections with the popliteal vein are multiple. During Duplex ultrasound assessment, as well as CT venography, they are often ignored due to their small caliber. Discussion and conclusions: Physiological hypothesis: At the knee level, The spongy bone of both tibia and femur epiphysis is an important place of production of red blood cells. They connect the venous system in the popliteal vein by several tiny perforators. In practice, these tiny perforators are not investigated and ignored by the sonographers. They should be distinguished from the big PVs of the tibial diaphysis responsible for varicose veins of the leg [1]. These PVs could also be linked to the so-called “phleboarthrosis” described recently [2]. The bony perforator veins of the knee are commonly responsible for reticular veins or telangiectases around the knee, but they are underdiagnosed by the sonographers. This explains why the injection of these cosmetic lesions around the knee frequently leads to recurrence.

Introduction: “Adductor canal syndrome”, or “Jogger’s syndrome” has been described as an unusual cause of acute arterial occlusion in younger men. It is also been identified as a cause of compressive neuropathy of the saphenous nerve. Nevertheless, femoral vein compression in the canal has never been described. Our aim is to describe the anatomy and physiology of Hunter’s canal, and to show that the femoral vein is much more exposed than the artery to compression inside the adductor hiatus, particularly at the outlet [1]. Material and methods: Fifty fresh cadavers were used to surgically expose the adductor hiatus for anatomical study. A series of 200 phlebographies and 100 CT venographies were also used to study the 3D morphology of the adductor hiatus. Results: Anatomically, in all cases we found that an abnormal musculotendinous band arose from the adductor magnus muscle, and joined the adductor tendon to the vastus medialis. The femoral vein is located more posteriorly and is frequently narrowed at this level : the edge of the vasto-adductor membrane. This was particularly true when the artery was calcified. Different types of anatomical compression of the femoral vein could by described, but the main is in the Hunter’s outlet: the edge of the vasto-adductor membrane. The resultant anatomical structure creates a notch with venous stenosis frequently occurring at the lower part of the hiatus, well seen in the cast of a femoral vein injected with latex and on the phlebographies In a majority of cases where such a stenosis was found, it was at the lower part of the canal, 13 to 15 cm above the femoral condyle. Compression by the artery or higher inside the canal could also be identified, but they are often ignored. Discussion and conclusion: Physiological hypothesis: The cadaveric simulations showed that contraction of the adductor longus closes the hiatus, and the adductor magnus opens it. Our hypothesis is that Hunter’s canal prevents femoro-popliteal axis reflux by synchronizing with calf pump ejection during ambulation. So in clinical practice, USD investigation should be a routine, seeking for a dilatation of the derivative routes, particularly the arcades of the semi-membranosus muscle: Compression of the femoral vein in the adductor canal is an underestimated cause of venous obstruction and deep vein thrombosis. Ultrasound investigation of both limbs should systematically be carried out at this precise level to prevent future venous obstruction from occurring here.

Introduction: The development of digital research at the level of the anatomy laboratory with the vascular surgery unit by anatomo-radiological interpretation based on 2D segmentation and 3D reconstruction [1] using serial sections of medical imaging (angiogram) for the aortic aneurysms, realizes a fundamental element in the diagnosis approach and offers a panel of tools adapted to the constraints of the clinical practice to optimize the decision of the surgical act and the restoration of the function. The objective of this study is to highlight the anatomical reports of aneurysm to improve the management of a 68-year-old patient. Materials and methods: The 256 sections of a CT angiogram of a 68-year-old patient with aortic aneurysm for exploration of chest pain. The morpho-anatomical study of the thoraco-abdominal visceral structures, as well as the posterior mediastinal region and the aneurysmal dilatations at the level of the aortic vascular axis is performed by the 3D volume rendering technique using OSIRIX® software [2]. Results: Interactive 3d modeling of the aorta was achieved with volume quantification of the aneurysm. Discussion and conclusion: The three-dimensional volumetric modeling of an aneurysm in a 68-year-old patient visualizes the thoraco-abdominal aortic dilatation and the importance of the aneurysm in the mediastinum on 3D reconstruction images, hence the surgical or endovascular indication and the technical management [3].

Not available

Objective To study of the microcirculatory effects of elastic compression stockings. Materials and methods In phlebology, laser Doppler techniques (flux or imaging) are widely used to investigate cutaneous microcirculation. It is a method used to explore microcirculation by detecting blood flow in skin capillaries. Flux and imaging instruments evaluate, non-invasively in real-time, the perfusion of cutaneous micro vessels. Such tools, well known by the vascular community, are not really suitable to our protocol which requires evaluation through the elastic compression stockings fabric. Therefore, we involve another instrument, called the Hematron (developed by Insa-Lyon, Biomedical Sensor Group, Nanotechnologies Institute of Lyon), to investigate the relationship between skin microcirculatory activities and external compression provided by elastic compression stockings. The Hematron measurement principle is based on the monitoring of the skin’s thermal conductivity. This clinical study examined a group of 30 female subjects, aged 42 years ±2 years, who suffer from minor symptoms of chronic venous disease, classified as C0s, and C1s (CEAP). Results The resulting figures show, subsequent to the pressure exerted by elastic compression stockings, an improvement of microcirculatory activities observed in 83% of the subjects, and a decreased effect was detected in the remaining 17%. Among the total population, the global average increase of the skin’s microcirculatory activities is evaluated at 7.63% ± 1.80% ( p Conclusion The results from this study show that the pressure effects of elastic compression stockings has a direct influence on the skin’s microcirculation within this female sample group having minor chronic venous insufficiency signs. Further investigations are required for a deeper understanding of the elastic compression stockings effects on the microcirculatory activity in venous diseases at other stages of pathology.

Based on previous experimental work with medical compression stockings it is proposed to restrict the term stiffness to measurements on the human leg and rather to speak about resistance when it comes to characterize the elastic property of compression hosiery in the textile laboratory.

Classic anatomical methods have failed to determine the precise location, origin and nature of nerve fibres in the inferior hypogastric plexus (IHP). The purpose of this study was to identify the location and nature (adrenergic and/or cholinergic) of IHP nerve fibres and to provide a three-dimensional (3D) representation of pelvic nerves and their relationship to other anatomical structures. Serial transverse sections of the pelvic portion of two human male fetuses (16 and 17 weeks’ gestation) were studied histologically and immunohistochemically, digitized and reconstructed three-dimensionally. 3D reconstruction allowed a ‘computer-assisted dissection’, identifying the precise location and distribution of the pelvic nerve elements. Proximal (supra-levator) and distal (infra-levator) communications between the pudendal nerve and IHP were observed. By determining the nature of the nerve fibres using immunostaining, we were able to demonstrate that the hypogastric nerves and pelvic splanchnic nerves, which are classically considered purely sympathetic and parasympathetic, respectively, contain both adrenergic and cholinergic nerve fibres. The pelvic autonomic nervous system is more complex than previously thought, as adrenergic and cholinergic fibres were found to co-exist in both ‘sympathetic’ and ‘parasympathetic’ nerves. This study is the first step to a 3D cartography of neurotransmitter distribution which could help in the selection of molecules to be used in the treatment of incontinence, erectile dysfunction and ejaculatory disorders.

Objective. To study the short term results of combined peroperative foam sclerotherapy (PFS) and surgical treatment for recurrent varicose veins. Methods. PFS was used to treat 129 limbs with recurrent varices: 100 great saphenous (GSV), 29 small saphenous veins (SSV). Foam was prepared with 1% polidocanol mixed with 4 times its volume of air. The 100 GSVs comprised 28 trunks directly connected with the femoral vein, 28 connected to a lymph node venous network, 11 associated with perforators and 33 isolated trunks. The 29 SSVs comprised 4 trunks directly connected to the popliteal vein, 7 isolated trunks, 15 popliteal perforators and 3 recanalisations after SSV stripping. All operations included phlebectomies. In twenty limbs re-ligation of the SFJ and 4 SPJs was carried out. All were performed under local anaesthesia in an ambulatory setting. Patients were assessed clinically and by colour duplex ultrasound after 3 and 40 days follow-up. Results. 120 patients (93%) showed complete obliteration of saphenous trunks, junctions and varices. The 9 incomplete obliterations were 3 venous recanalisations in the SSV compartment and 6 perforators (4 popliteal and 2 femoral). Two asymptomatic deep venous thromboses were detected by colour duplex 3 days after operation. Conclusion. PFS facilitates surgical treatment of recurrent varicose veins. There is a small risk of post-operative deep vein thrombosis.

BackgroundCorona phlebectatica (corona) is a clinical sign associated with chronic venous disorders but is not yet included in the CEAP classification. Our aim was to analyze the clinical and hemodynamic correlations of corona to determine its significance and potential usefulness in classification grading and systems such as the CEAP classification.MethodsA full clinical and duplex ultrasound record of 287 patients was collected by 60 vascular physicians from 10 European countries. They used the same computer software. This was designed to improve the interobserver consistency of computer-assisted procedures for clinical data gathering. Corona was defined as fan-shaped intradermal telangiectases in the medial and sometimes lateral portions of the ankle and foot. This definition was further refined into three severity grades of light, moderate, and severe, according to reference pictures provided by the software. To avoid overpowering the statistical tests, only data from right lower limbs were analyzed.ResultsIn this series of 287 unselected patients, a corona was detected in 96 right lower limbs (27.7%) and graded as light in 61 (21.1%), moderate in 24 (8.3%), and severe in 11 (3.8%). The presence of a corona and its severity grade were found significantly related to two risk factors of chronic venous disorders (age and personal history of deep vein thrombosis), the presence of so-called venous symptoms, including pain, pruritus, burning sensation, feeling of swelling, cramps, heavy legs; and most individual items of CEAP clinical classes (varicose veins, edema, all skin changes, C5; and open ulcers, C6). Furthermore, among the patients without skin changes (classes C1 to C3), the presence and grade of corona appeared to be significantly associated with the severity of the disease, with increasing CEAP (P < .05), disability (P < .03), and anatomic (P < .01) scores. The presence of a corona and its severity grade were also found significantly related to the CEAP clinical classes themselves (P < .001), the CEAP disability (P < .001) and clinical severity scores (P < .001), and the presence of superficial reflux in the saphenous and nonsaphenous territories (P = .05) and in the perforators (P < .001). The presence of a deep venous reflux was not found to be significant in this series. The relative risk of finding incompetent leg or calf perforators by duplex ultrasound is 4.4 times greater in patients with corona (P < .001). A comparison between the CEAP classification without corona and a modified classification including corona in C3 shows a better reliability coefficient of Cronbach.ConclusionCorona strongly correlates with the clinical severity and hemodynamic disturbances of the disease. The inclusion of corona in the C3 class should probably improve the reliability of the CEAP clinical classes.

International audience