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BACKGROUND: Anatomical variations of the external jugular vein (EJV) are important because of their notable implications for flap design and diagnostic procedures, including EJV cannulation. CASE REPORT: This case report describes a unique venous anomaly observed during dissection of the right posterior cervical triangle in an adult male body donor. Notably, the EJV terminated atypically by forming a venous loop with the transverse cervical vein. This loop comprised three segments: a proximal segment formed by the EJV, a distal segment formed by the transverse cervical vein, and an intervening midsegment. From the convexity of the loop, two veins arose, running parallel for approximately 2.5 cm before piercing the investing layer of the deep cervical fascia and draining separately into the subclavian vein (SCV). RESULTS: The first vein (V1) entered the SCV 1.77 cm distal to the clavicular head of the sternocleidomastoid muscle (SCM), while the second (V2) did so 2.57 cm distal to the same landmark. Additionally, the posterior external jugular vein (PEJV), an infrequent finding, was observed running along the anterior border of the trapezius muscle and draining into the transverse cervical vein instead of the EJV. The suprascapular vein, rather than opening into the EJV, drained directly into the SCV. CONCLUSIONS: These findings underscore the significance of acknowledging such rare venous variations to avoid potential complications during surgical procedures involving the neck region.

Purpose To investigate the prevalence and clinical characteristics of diabetic patients with retinal venous loops (RVLs) and to assess the association with retinal ischemia using widefield swept-source optical coherence tomography angiography (WF SS-OCTA).MethodsIn this retrospective, cross-sectional study, a total of 195 eyes of 132 diabetic patients (31 eyes with no diabetic retinopathy (DR), 76 eyes with nonproliferative DR (NPDR), and 88 eyes with proliferative DR (PDR)) were imaged with WF SS-OCTA using Angio 6 × 6 mm and Montage 15 × 15 mm scans. Quantitative ischemia-related parameters, including ischemia index (ratio of nonperfusion area to total retinal area), foveal avascular zone (FAZ), and neovascularization features, were evaluated. RVLs were classified as type I or type II according to the branching level of the feeder vessel. A multivariate generalized estimating equations (GEE) logistic regression model was used to analyze the association of systemic parameters and ischemia-related metrics with RVLs in PDR eyes.ResultsForty-eight RVLs were identified in 22 eyes (11.28%). The prevalence of RVLs was higher in PDR compared to NPDR eyes (21.59% vs. 3.95%, P < 0.05). Type II RVLs accounted for a higher proportion than type I (89.58% vs. 10.42%, P < 0.001). RVLs were more likely to originate from superior (vs. inferior) and temporal (vs. nasal) veins (P < 0.05). The GEE model showed that neovascularization (NV) flow area and diastolic blood pressure were associated with RVLs in the PDR group (P < 0.05).ConclusionWF SS-OCTA is useful for the identification of RVLs in patients with DR. NV flow area and diastolic blood pressure were associated with the presence of RVLs in eyes with PDR. Ischemia index, FAZ, and other WF SS-OCTA parameters were not associated with RVLs. Further longitudinal studies are needed to identify the role of RVLs in DR progression.

Background The free flap transfer of a latissimus dorsi flap (LDF) for the closure of sacral wound defects after pelvic exenteration and radiation therapy offers a successful tool of the plastic surgeon. This case report shows the successful coverage using an upstream arterio-venous (AV) loop in combination with an LDF. Case presentation We describe the case of a patient who underwent a pelvic exenteration and radiation therapy due to a local recurrence of rectal cancer. The initially used VRAM flap could not ensure a satisfactorily wound closure. An interdisciplinary approach first yielded an AV loop using both greater saphenous veins and was connected to the arteria and vena femoris followed by a free LDF transfer, which was performed 11 days later. The result was an excellent reconstructive and plastic coverage of the sacral wound defect with a well-perfused LDF. The long-term result showed a perfectly integrated flap in the sacral region. Conclusion We recommend the free LDF for the coverage of large wound defects in irradiated areas after the failure of VRAM flap. If an AV loop is necessary within the flap transfer, we recommend conducting two procedures to guarantee the perfusion of the AV loop.

Extracorporeal Membrane Oxygenation (ECMO) is a modality of extracorporeal life support which allows temporary support in cases of cardiopulmonary failure and cardiogenic shock. This study presents a valveless pump that works by the Liebau effect as a possible pumping system in ECMO circuits, replacing the current roller and centrifugal pumps. For this purpose, a mock circulatory loop emulating the haemodynamic of the right part of the heart has been constructed. A veno-venous ECMO circuit with the integrated Liebau pump has been incorporated to analyse its performance. The Liebau pump in the ECMO circuit showed a flow assistance in the range of paediatric ECMO and low blood flow range for adults. In addition, experimental tests conducted demonstrated the advantage of the Liebau pump over currently used pumps as the ability to generate a pulsatile flow, which has many advantages in biomedical applications.

Cognitive deterioration and the transition to neurodegenerative disease does not develop through simple, linear regression; it develops as rapid and global transitions from one state to another within the neural network. Developing understanding and control over these events is among the largest tasks facing contemporary neuroscience. This paper will discuss a conceptual reframing of cognitive decline as a transitional phase of the functional state of complex neural networks resulting from the intertwining of molecular degradation, vascular dysfunction and systemic disarray. The paper will integrate the latest findings that have demonstrated how the disruptive changes in glymphatic clearance mechanisms, aquaporin-4 polarity, venous output, and neuroimmune signaling increasingly correlate with the neurophysiologic homeostasis landscape, ultimately leading to the destabilization of the network attraction sites of memory, consciousness, and cognitive resilience. Furthermore, the destabilizing processes are exacerbated by epigenetic silencing; neurovascular decoupling; remodeling of the extracellular matrix; and metabolic collapse that result in accelerating the trajectory of neural circuits towards the pathological tipping point of various neurodegenerative diseases including Alzheimer’s disease; Parkinson’s disease; traumatic brain injury; and intracranial hypertension. New paradigms in systems neuroscience (connectomics; network neuroscience; and critical transition theory) provide an intellectual toolkit to describe and predict these state changes at the systems level. With artificial intelligence and machine learning combined with single cell multi-omics; radiogenomic profiling; and digital twin modeling, the predictive biomarkers and early warnings of impending collapse of the system are beginning to emerge. In terms of therapeutic intervention, the possibility of reprogramming the circuitry of the brain into stable attractor states using precision neurointervention (CRISPR-based neural circuit reprogramming; RNA guided modulation of transcription; lineage switching of glia to neurons; and adaptive neuromodulation) represents an opportunity to prevent further progression of neurodegenerative disease. The paper will address the ethical and regulatory implications of this revolutionary technology, e.g., algorithmic transparency; genomic and other structural safety; and equity of access to advanced neurointervention. We do not intend to present a list of the many vertices through which the mechanisms listed above instigate, exacerbate, or maintain the neurodegenerative disease state. Instead, we aim to present a unified model where the phenomena of molecular pathology; circuit behavior; and computational intelligence converge in describing cognitive decline as a translatable change of state, rather than an irreversible succumbing to degeneration. Thus, we provide a framework for precision neurointervention, regenerative brain medicine, and adaptive intervention, to modulate the trajectory of neurodegeneration.

Following the exhaustion of all conventional hemodialysis access options in the upper extremities, a prosthetic arteriovenous loop was performed between the brachial artery (BA) and the external jugular vein (EJV) as a novel access option for hemodialysis in the present case report. During the procedure, a polytetrafluoroethylene graft was anastomosed to the BA and the EJV, and looped on the upper limb. The safety and reliability of BA-EJV access was evaluated by determining the complications, patency and intervention rates. The patient was then followed up for 20 months. The graft became thrombosed 20 months after the placement. There were no complications, such as infection, bleeding or aneurysmal lesions. Overall, the present study demonstrates that hemodialysis via BA-EJV access represents an unusual, yet effective and safe procedure, which may be conducted with acceptable complications and patency rates.

We describe early-onset diabetes in a 6-month-old patient carrying an LRBA gene mutation. Mutations in this gene cause primary immunodeficiency with autoimmune disorders in infancy. At admission, he was in diabetic ketoacidosis, and treatment with fluid infusion rehydration and then i.v. insulin was required. He was discharged with a hybrid closed-loop system for insulin infusion and prevention of hypoglycemia (Minimed Medtronic 670G). He underwent a next-generation sequencing analysis for monogenic diabetes genes, which showed that he was compound heterozygous for two mutations in the LRBA gene. In the following months, he developed arthritis of hands and feet, chronic diarrhea, and growth failure. He underwent bone marrow transplantation with remission of diarrhea and arthritis, but not of diabetes and growth failure. The blood glucose control has always been at target (last HbA1c 6%) without any severe hypoglycemia. LRBA gene mutations are a very rare cause of autoimmune diabetes. This report describes the clinical course in a very young patient. The hybrid closed-loop system was safe and efficient in the management of blood glucose. This report describes the clinical course of diabetes in a patient with a novel LRBA gene mutation.

Abstract Background : Inferior vena cava (IVC) filter placement still plays an essential role in preventing pulmonary embolism (PE) in patients with contraindications to anticoagulant therapy. However, IVC filter placement does have long-term risks which may be mitigated by retrieving them as soon as clinically acceptable. A dedicated IVC filter clinic provides a potential means of assuring adequate follow-up and retrieval. Aim : To assess the efficacy of our Inferior vena cava (IVC) filter retrieval clinic at improving the rate of patient follow-up, effective filter management, and retrieval rates. Materials and Methods : During the period of August 2017 through July 2018, 70 IVC filters were placed at our institution, and these patients were automatically enrolled into our IVC filter retrieval clinic for quarterly follow-up. We retrospectively reviewed data including appropriateness for removal at 3 months, overall retrieval rates, removal technique(s) employed, and technical success. Results : 62.9% of the potentially retrievable filters were removed during the study period. The technical success of extraction, using a combination of standard and advanced techniques, was 91.7%. Overall, 15% of the patients were lost to follow-up. Conclusion : Our findings add to the growing body of literature to support the need for a robust IVC filter retrieval clinic to ensure adequate follow-up and timely retrieval of IVC filters.

Purpose Removal of an adhered indwelling catheter in a totally implantable venous access device (TIVAD) can occasionally be challenging, particularly after prolonged implantation. The purpose of this paper is to present a modified endovascular technique for difficult TIVAD removal and to highlight its clinical relevance in cases where the catheter is firmly adhered to the vessel wall, making standard removal methods challenging. Materials and methods Between December 2015 and April 2025, a total of 3347 TIVADs were implanted, and 367 removal procedures were conducted. Among these, 355 (96.7%) catheters were successfully removed using the standard technique. Three (0.8%) were removed using the push-in techniques, and one (0.3%) was removed using the contralateral pull-through combined with the sheath-twist technique. In 8 (2.2%), the ipsilateral pull-through technique was required after failure of the initial approaches. The ipsilateral pull-through technique was performed using an introducer sheath and a handmade loop-snare constructed from a guidewire and a seeking catheter. Patient characteristics and procedural data were collected for analysis. Results The ipsilateral pull-through technique was successfully used to remove difficult-to-remove TIVADs in 7 of 8 patients. In the remaining patient, the indwelling catheter was firmly adhered to the segment extending from the innominate vein to the superior vena cava, where antegrade flow was absent and numerous collateral vessels were present. Although the occlusion was successfully crossed, catheter removal was aborted due to severe pain and concerns about potential superior vena cava rupture. One procedure-related complication was observed: catheter fracture on follow-up computed tomography in one of the seven successful cases. No other complications were observed. The subclavian vein, innominate vein, and superior vena cava were patent on follow-up computed tomography performed for cancer evaluation. The median indwelling duration in this cohort was 2473 days (interquartile range [IQR], 2017–3002 days), and the median procedure time was 60 min (IQR, 45.8–74.8 min). Conclusion The ipsilateral pull-through technique is a useful method to detach adhered catheters during difficult TIVAD removal. Level of evidence Level 3, Retrospective Study.

Background: Transesophageal echocardiography (TEE) is mandatory before transvenous lead extraction (TLE), but its usefulness remains underestimated. This study aims to describe the broad range of TEE findings in TLE candidates, as well as their influence on procedure complexity, major complications (MCs) and long-term survival. Methods: Preoperative TEE was performed in 1191 patients undergoing TLE. Results: Lead thickening (OR = 1.536; p = 0.007), lead adhesion to heart structures (OR = 2.531; p < 0.001) and abnormally long lead loops (OR = 1.632; p = 0.006) increased the complexity of TLE. Vegetation-like masses on the lead (OR = 4.080; p = 0.44), lead thickening (OR = 2.389; p = 0.049) and lead adhesion to heart structures (OR = 6.341; p < 0.001) increased the rate of MCs. The presence of vegetations (HR = 7.254; p < 0.001) was the strongest predictor of death during a 1-year follow-up period. Conclusions: TEE before TLE provides a lot of important information for the operator. Apart from the visualization of possible vegetations, it can also detect various forms of lead-related scar tissue. Build-up of scar tissue and the presence of long lead loops are associated with increased complexity of the procedure and risk of MCs. Preoperative TEE performed outside the operating room may have an impact on the clinical decision-making process, such as transferring potentially more difficult patients to a more experienced center or having the procedure performed by the most experienced operator. Moreover, the presence of masses or vegetations on the leads significantly increases 1-year and all-cause mortality.