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Summary Background Latissimus dorsi flap is the gold standard for pedicled breast reconstruction but is limited by donor site scarring, which is difficult to conceal, and a high rate of post-operative seroma. We investigated the anatomic characteristics and feasibility of using a subcostal artery perforator (SCAP) flap, which was taken from the flank area and vascularised by a perforator artery through a subcostal pedicle, for a breast reconstruction. Methods A literature review was undertaken to determine the anatomy of the SCAP flap pedicle and the vascular supply to this dermal-fat flap. Pedicled SCAP flaps were dissected on cadavers to identify the anatomy of the perforator arteries and the pedicle length. Pedicled SCAP flaps were then tunnelled through the chest area to evaluate their feasibility for breast reconstruction. Results Twelve SCAP flaps were prepared on six cadavers. Mean pedicle length was 17 cm (14.5–20 cm). Mean flap size was 13 × 18 cm (11.5 × 15.5–15 × 21 cm). For each flap, a pedicle of sufficient length was dissected to allow the tunnelling of the flap and to perform breast reconstruction with a dermal-fat flap of adequate size. In all cases, an SCAP flap was prepared, without taking muscle, to reduce the risk of parietal complications at the donor site in future clinical applications. Conclusion Pedicled SCAP flap is a feasible option in breast reconstruction and could represent a less arduous surgical alternative to free flaps for some patients. Donor site scarring was acceptable. Clinical application of SCAP flaps should be investigated further.

Postoperative bleeding is a dangerous complication after percutaneous nephrolithotomy (PCNL). Pseudoaneurysm, arteriovenous fistula, and arterial laceration are the three most common causes of post-PCNL bleeding. Subcostal artery bleeding is a rare cause. We herein present a clinical case involving a 43-year-old man who presented with right renal complex calculi and was managed by PCNL in the prone position using an inferior calyceal puncture approach. Intermittent extreme bleeding occurred 1 day postoperatively, and immediate renal angiography was performed. However, we found no sign of a pseudoaneurysm, arteriovenous fistula, or arterial laceration. Another well-trained and experienced doctor also found no pseudoaneurysm, arteriovenous fistula, or arterial laceration. After adjusting the catheter position, subcostal artery bleeding finally appeared and was successfully controlled by coils. This finding indicates that subcostal artery damage is one cause of post-PCNL bleeding. We suggest that clinicians should carefully and patiently perform angiography and/or embolization to avoid misdiagnosis and mistreatment.

In order to advance the state-of-the-art in computational aortic biomechanics, we investigated the influence of (i) a non-uniform wall thickness, (ii) minor aortic side branches and (iii) a non-uniform axial stretch distribution on the location of predicted hotspots of principal strain in a mouse model for dissecting aneurysms. After 3 days of angiotensin II infusion, a murine abdominal aorta was scanned in vivo with contrast-enhanced micro-CT. The animal was subsequently sacrificed and its aorta was scanned ex vivo with phase-contrast X-ray tomographic microscopy (PCXTM). An automatic morphing framework was developed to map the non-pressurized, non-stretched PCXTM geometry onto the pressurized, stretched micro-CT geometry. The output of the morphing model was a structural FEM simulation where the output strain distribution represents an estimation of the wall deformation, not only due to the pressurization, but also due to the local axial stretch field. The morphing model also included minor branches and a mouse-specific wall thickness. A sensitivity study was then performed to assess the influence of each of these novel features on the outcome of the simulations. The results were supported by comparing the computed hotspots of principal strain to hotspots of early vascular damage as detected on PCXTM. Non-uniform axial stretch, non-uniform wall thickness and minor subcostal arteries significantly alter the locations of calculated hotspots of maximal principal strain. Even if experimental data on these features are often not available in clinical practice, one should be aware of the important implications that simplifications in the model might have on the final simulated result.

Background: Locoregional flaps are sufficient in most sacral reconstructions. However, large sacral defects due to malignancy necessitate a different reconstructive approach, with local flaps compromised by radiation and regional flaps inadequate for broad surface areas or substantial volume obliteration. In this report, we present our experience using free muscle transfer for volumetric reconstruction in such cases, and demonstrate 3D haptic models of the sacral defect to aid preoperative planning. Methods: Five consecutive patients with irradiated sacral defects secondary to oncologic resections were included, surface area ranging from 143-600cm2. Latissimus dorsi-based free flap sacral reconstruction was performed in each case, between 2005 and 2011. Where the superior gluteal artery was compromised, the subcostal artery was used as a recipient vessel. Microvascular technique, complications and outcomes are reported. The use of volumetric analysis and 3D printing is also demonstrated, with imaging data converted to 3D images suitable for 3D printing with Osirix software (Pixmeo, Geneva, Switzerland). An office-based, desktop 3D printer was used to print 3D models of sacral defects, used to demonstrate surface area and contour and produce a volumetric print of the dead space needed for flap obliteration. Results: The clinical series of latissimus dorsi free flap reconstructions is presented, with successful transfer in all cases, and adequate soft-tissue cover and volume obliteration achieved. The original use of the subcostal artery as a recipient vessel was successfully achieved. All wounds healed uneventfully. 3D printing is also demonstrated as a useful tool for 3D evaluation of volume and dead-space. Conclusion: Free flaps offer unique benefits in sacral reconstruction where local tissue is compromised by irradiation and tumor recurrence, and dead-space requires accurate volumetric reconstruction. We describe for the first time the use of the subcostal artery as a recipient in free flap sacral reconstruction. 3D printing of haptic bio-models is a rapidly evolving field with a substantial role in preoperative planning.

Summary Background The objective of the current study is to elucidate the three-dimensional vascular distribution as far as the peripheral areas of a latissimus dorsi musculocutaneous flap and to establish a safe procedure for creating it. Methods A lead oxide with gelatin-contrast agent was injected into fresh cadavers and the angiosomes in the muscle and skin were examined in detail. Results In the muscle, three vascular territories were observed. The first vascular territory was formed by the thoracodorsal artery, the perforating branches of the ninth intercostal artery and those of the tenth intercostal artery located in the lateral part of the muscle. The second vascular territory was formed by the perforating branches of the tenth intercostal artery located in the medial part of the muscle, those of the 11th intercostal artery and the subcostal artery. The third vascular territory was formed by perforating branches of the first and second lumbar arteries. In the dorsal skin above the muscle, two vascular territories were observed. The first vascular territory was formed by perforating cutaneous branches of the thoracodorsal artery, perforating branches of the ninth through 11th intercostal arteries and the scapular circumflex artery. The second vascular territory was formed by perforating branches of the subcostal artery and the first and second lumbar arteries. Conclusions When using a latissimus dorsi musculocutaneous flap with the thoracodorsal artery as a pedicle, the flap can be safely elevated as far as the inferior border of the 12th rib where perforating branches of the subcostal artery are distributed. At the same time, skin above the muscle can be safely harvested up to the iliac crest. It is essential, however, that the skin paddle includes perforating branches of the ninth intercostal artery or perforating branches of the 10th intercostal artery in the lateral part of the muscle.

Summary Background Based on a previous clinical case report in which the pedicled subcostal artery perforator flap allowed for the closure of a large defect of the lumbar region, the present study was designed to investigate the anatomy of the subcostal artery perforator flap and to evaluate its potential for wider clinical use. Methods A series of 14 human cadavers was studied and 28 subcostal artery perforator flaps were dissected. The location of the perforator vessel was charted against anatomical landmarks. Measurements included the perforator calibre, pedicle length, and flap size following methylene blue injection. The findings were compared by Doppler sonography in 15 volunteers. Results The subcostal artery perforator was present in all dissected specimens and in all volunteers. Its calibre measured in mean 2mm. The location was constant at the lateral border of the latissimus dorsi muscle and between 1 and 3cm below the lower rib end. The pedicle length reached a mean of 10.5cm when dissected up to the border of the erector spinae musculature. The vascular supply covered a mean flap size of 10×14cm. The in vivo investigations confirmed the constant perforator location from the anatomical landmarks. Conclusion This anatomical study reveals a considerable potential for the clinical use of the subcostal artery perforator flap for defect coverage in the lumbar area, due to its constant and reliable anatomy. Doppler sonography can be helpful in preoperative assessment of the size and the position of the subcostal perforator, thus allowing for an optimal flap design.

Abdominal wall hematoma is an uncommon cause of acute abdominal pain. We report a case of internal oblique hematoma caused by rupture of the subcostal artery in a 57-year-old woman. Ultrasonography (US) showed a hypoechoic mass in the right lateral abdominal wall. Contrast-enhanced computed tomography (CT) showed a large soft tissue mass with extravasation of contrast medium located in the right internal oblique muscle. Angiography showed contrast extravasation from the subcostal artery, and transcatheter arterial embolization was performed successfully.

We report a new treatment for excessive spasticity using an endovascular technique. A 52-year-old woman with intractable spasticity of the hip joints and abdominal muscles was treated with an injection of 70% alcohol into Adamkiewicz's artery, which destroyed the spinal cord fed by Adamkiewicz's artery and cut the reflex arcs of excessive spasticity. Immediately after the treatment a significant change was noticed in muscle tonicity of the lower extremities, and intractable spasticity disappeared. Skin necrosis and muscle damage occurred because of the alcohol that leaked into the muscle branch of the subcostal artery. However, these complications could be treated by simple necrotomy. No recurrence was observed during the follow-up period. We believe this endovascular treatment will become a new strategy for excessive spasticity arising from spinal cord injury.

We present a case of origin of the left 8th to 11th intercostal, right 7th to 11th intercostal and both subcostal arteries from a common trunk arising dorsally off the aorta at the level of the first lumbar vertebral body (figure ​(figure1).1). Aside from being unique in our experience, there is no simple explanation for the embryological origin of a common trunk with bilateral intercostal distribution. Figure 1 The patient, a 45-year-old woman, was undergoing preoperative spinal angiography to identify the origin of the artery of thoracolumbar enlargement before surgery on a congenital kyphosis with associated fusion abnormalities (figure ​(figure2).2). The artery of Adamkiewicz arose from the right subcostal artery (figure ​(figure1).1). The vascularisation of the spinal cord appeared to have conventional topography at the thoracolumbar level. Figure 2 There is recognised variability in the size, number and site of origin of the intercostal arteries 1,2,3. The typical pattern in the lower thoracic region is paired distribution directly off the aorta. Variations include hypoplasia and atresia of individual intercostal arteries, usually with reconstitution of the vessel concerned by anastomotic channels from adjacent levels. These anastomoses are usually proximal, though if the anastomosis develops further distally, the proximal portion of the intersegmental precursor of the intercostal artery may persist as an isolated segment and has been described as supplying the artery of thoracolumbar enlargement11. Supernumerary intercostal arteries or vessels with a partial or complete septum may also be seen. Where common trunks arise, these typically supply two or more ipsilateral intercostal arteries, sometimes with additional supply to bronchi or more rarely other viscera. A common trunk to both left and right intercostal arteries at one level is also relatively common, especially at more caudal levels. It has been noted that the aorta may bridge the apex of a kyphosis4,5,6. An association between variability of aortic branches 6 and specifically of the intercostal and segmental arteries5,6 has also been described in patients with kyphosis. In vertebral body maldevelopment, vascular anomalies and in particular variation in segmental artery distribution has been described 4. The vascular anomalies do not necessarily occur at the level of vertebral body abnormality5. In zebrafish, development of the dorsal aortae and other midline structures is probably influenced by the notochord7. If this is also true in humans, it may explain the association between vertebral body and vascular maldevelopment. On the other hand, ischaemia due to proximal occlusion of the intercostal arteries has been demonstrated to cause scoliosis, probably due to abnormal neuromuscular function in the paravertebral muscles8. The intercostal arteries are derived from the intersegmental arteries, in turn arising from the initially paired dorsal aortae that run the entire length of the embryo. These normally fuse to form a single dorsal aorta, early in development. This fusion occurs just caudal to the branchial/pharyngeal arches. Paired intersegmental arteries arise from the dorsal aorta to pass between the somites. In the neck, these join to form the vertebral arteries and most of the original connections to the dorsal aorta disappear. The paired intersegmental arteries are said to persist in the thorax as the paired intercostal arteries and in the abdomen as the paired lumbar arteries1,9. The median sacral artery represents the caudal end of the fused dorsal aortae and their intersegmental branches. If this conventionally held belief is accurate, it is difficult to explain the existence of a common trunk arising from the thoracic aorta with multiple intercostal arteries to both sides arising from it. If the intersegmental arteries persist unaltered as the intercostal arteries then a trunk to bilateral intercostal arteries and a separate descending thoracic aorta imply either that the trunk: 1) was derived directly from both dorsal aortae with their intersegmental arteries attached or 2) was derived from the definitive aorta and intercostal arteries after fusion of the dorsal aortae or 3) represents one dorsal aorta with its intersegmental arteries and the contralateral intersegmental arteries were transferred to the trunk from the contralateral dorsal aorta which persisted as the definitive aorta or 4) was derived from a longitudinal vessel other than the definitive aorta or dorsal aortae. The first of these hypotheses seems improbable as the definitive aorta represents the fused dorsal aortae. The second seems equally unlikely, as it would necessitate detachment of a long segment of definitive aortic wall with its attached intercostal arteries, after fusion of the dorsal aortae. In connection with the third of these mechanisms, it is interesting to note that caudal to the seventh intersegmental artery, the right dorsal aorta ordinarily disappears, to reappear inferiorly and fuse with the left dorsal aorta to form the descending thoracic aorta1 A possible explanation for this common trunk is anomalous persistence of part of the right dorsal aorta and its attached intersegmental arteries, though for a trunk with bilateral distribution, either there would have to be subsequent transfer of the corresponding left intersegmental arteries or the intersegmental arteries would have to arise in situ and fuse with the nearest (in this case anomalous) vessel. The fact that a segment of the right dorsal aorta normally regresses implies that in the normal course of development the intercostal arteries are capable of deriving their origin from a vessel other than the dorsal aorta from which their intersegmental precursor arose. Candidates for the longitudinal vessel of the fourth hypothesis include the precostal anastomoses, which may be present between the intersegmental arteries1 Superior intercostal arteries represent the persistence of these longitudinal anastomotic channels 1,10. The configuration of this common trunk has similarity to the superior intercostal arteries, however, they are not bilateral and are more superior. A possible explanation for this anomalous trunk is fusion of persistent bilateral longitudinal precostal anastomoses and their associated intersegmental vessels. This hypothesis is appealing as it avoids having to postulate transfer of intersegmental or intercostal vessels. Instead, if the original connections of the longitudinal precostal anastomoses to the dorsal aortae (the proximal parts of the intersegmental arteries) gradually regressed, paired longitudinal trunks with unilateral distribution, analogous to superior intercostal vessels would result. The final step would then involve fusion of these paired trunks in the median plane, a recognised phenomenon where a bridging structure exists10. This fascinating variant has revealed an absence of in-depth understanding of the behaviour of the intersegmental arteries and dorsal aortae during embryogenesis. The fact that this variant occurred in the presence of a segmentation anomaly within the somites may indicate an interaction with a cranio-caudal and lateralising mechanism that governs the establishment of the normal (and abnormal) vascular pattern.

The arrangement of extraspinal sources of the spinal cord arterial supply in man is more complicated than previously described, especially with regard to the origin and branching of the aortic segmental arteries. The fact that other arteries in the neck than the vertebral artery, such as the costo-cervical trunk and the ascending cervical artery may contribute to the supply of the cervical cord is confirmed, and also the occurrence of two or more spinal branches from different sources entering the same intervertebral foramen. Frequent occurrence of two or more segmental arteries arising from a common stem and variations in the branching of the subcostal arteries were found; their functional significance on the spinal cord circulation is not known. The fact that no significant anterior root artery was ever seen at the level of the vascular anomaly suggests that the anomaly is of no clinical importance. Nevertheless, obstruction of a common stem entail the risk of spinal cord infarction due to involvement of an important posterior root artery. On the other hand, the spinal cord seems to be fairly well protected against ischaemic injury following limited interference with the extraspinal arteries due to a profuse supply of intra- and extraspinal collaterals.