Volume 134, Number 3 • Viewpoints

Fig. 2. (Left) Preoperative view. (Right) Postoperative view after reconstruction.

superficial circumflex vessels or superficial inferior epigastric vessels would have been the primary option for addressing both the mastectomy defects and lymphedema in the absence of venous thromboembolic disease history.4 The lateral thoracic lymph nodes have been described as a potential donor site that can be harvested to treat both upper and lower extremity lymphedema.5 Because the lateral thoracic vessels communicate with the thoracodorsal vascular pedicle, elevation of a chimeric latissimus dorsi myocutaneous flap with a second pedicle to the lymph nodes is possible. As breast cancer treatment continues to evolve with increasing numbers of survivors, plastic and reconstructive surgeons are expected to encounter more patients with upper extremity lymphedema. In this particular subset of patients who are not candidates for microvascular procedures, a chimeric latissimus flap with vascularized lymph nodes provides an excellent option not only for breast reconstruction but also for lymphedema management. DOI: 10.1097/PRS.0000000000000469

Dev Vibhakar, D.O. Division of Plastic and Reconstructive Surgery

Sanjay Reddy, M.D. Department of Surgical Oncology

Wilma Morgan-Hazelwood, O.T.R./L., C.L.T./L.A.N.A. Department of Rehabilitation Therapy

Eric I. Chang, M.D. Division of Plastic and Reconstructive Surgery Fox Chase Cancer Center Philadelphia, Pa.

Correspondence to Dr. Chang Division of Plastic and Reconstructive Surgery Fox Chase Cancer Center 50 Huntingdon Pike, 3rd Floor Rockledge, Pa. 19046 [email protected]

disclosure The authors have no financial interest to declare in relation to the content of this article. references 1. DiSipio T, Rye S, Newman B, Hayes S. Incidence of unilateral arm lymphoedema after breast cancer: A systematic review and meta-analysis. Lancet Oncol. 2013;14:500–515. 2. Ugur S, Arıcı C, Yaprak M, et al. Risk factors of breast cancerrelated lymphedema. Lymphat Res Biol. 2013;11:72–75. 3. Chang DW, Suami H, Skoracki R. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of ­extremity lymphedema. Plast Reconstr Surg. 2013;132:1305–1314. 4. Saaristo AM, Niemi TS, Viitanen TP, Tervala TV, Hartiala P, Suominen EA. Microvascular breast reconstruction and lymph node transfer for postmastectomy lymphedema patients. Ann Surg. 2012;255:468–473. 5. Becker C, Vasile JV, Levine JL, et al. Microlymphatic surgery for the treatment of iatrogenic lymphedema. Clin Plast Surg. 2012;39:385–398.

Radial Arteriovenous Fistula following Percutaneous Coronary Intervention: A Rare Case Sir:

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ercutaneous coronary intervention has traditionally been performed through a transfemoral approach. However, transradial access has increased in popularity with interventional cardiologists because of its easy accessibility, quick ambulation, and shorter hospital stay.

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Plastic and Reconstructive Surgery • September 2014 Although percutaneous coronary intervention through the transradial approach has advantages, it is not completely free of the complications experienced with the transfemoral approach, including hematoma, pseudoaneurysm, and pain. Arteriovenous fistula of the radial artery is a rare complication, with only five cases previously published worldwide. We report a case of arteriovenous fistula occurring after coronary intervention using the transradial approach.1–3 A 61-year-old woman presented to the emergency department with increasing pain and paresthesias in her right dominant distal wrist and hand over the prior 2 months. In addition, she was experiencing pain radiating up the arm and into the right shoulder. A coronary origin of pain was eliminated by the medical team. The patient had received a percutaneous coronary intervention with stenting of the left anterior descending artery 3 months before admission through the right radial artery at the wrist. Physical examination demonstrated a 2-cm superficial compressible mass with easily palpable thrill over the previous radial puncture site. There was normal arterial filling of the hand, an intact arch, and diminished sensibility in the median nerve distribution. Duplex ultrasound confirmed an arteriovenous fistula between the distal radial artery and the adjacent venae comitantes (Fig. 1). Operative exploration revealed an engorged mass with a tortuous proximal ulnar vena comitans. Resection of the arteriovenous mass was performed with primary microvascular reanastomosis of the radial artery and ligation of veins (Fig. 2). Postoperatively, the patient had complete resolution of her radiating pain and paresthesias of the median nerve. At 3-month follow-up, the radial artery remained patent, with preservation of antegrade flow. An arteriovenous fistula is an abnormal connection between an artery and vein resulting in a disrupted blood flow pattern. Arteriovenous fistulas may occur congenitally, be surgically created for hemodialysis, or result from trauma or erosion of an arterial aneurysm. Femoral arteriovenous fistulas are a well-documented complication of cardiac catheterization by a femoral approach, occurring at an incidence of approximately 1 percent in the modern era.1,2,4 (See Video, Supplemental Digital Content 1, which shows pertinent clinical and intraoperative findings demonstrating radial arteriovenous fistula. This video demonstrates duplex asound findings, intraoperative dissection, and gross specimen following resection, http://links.lww.com/PRS/B73.) In contrast, arteriovenous fistulas of the radial artery following catheterization are exceedingly Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s Web site (www.PRSJournal.com).

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Fig. 1. Doppler ultrasonographic image demonstrating continuous turbulent flow between the radial artery and venae comitantes.

Fig. 2. Intraoperative gross dissection visualizing fistula connecting the radial artery and venae comitantes.

rare, with only two previous reports published in the English-language medical literature. Only small veins are present in the vicinity of the radial puncture site, making arteriovenous fistulas in this region less likely than other vascular complications such as pseudoaneurysms. Duplex ultrasound is the preferred diagnostic tool for confirmation of arteriovenous fistulas. Although radial artery arteriovenous fistulas are rare, the rapidly growing popularity of percutaneous coronary intervention suggests an increased incidence in the future and stresses the importance of clinical suspicion, proper diagnosis, and early surgical intervention.1–4 DOI: 10.1097/PRS.0000000000000481

J. Walter Dutton, M.D. West Virginia University School of Medicine

W. Thomas McClellan, M.D. Plastic and Reconstructive Surgery West Virginia University Morgantown, W.Va.

Volume 134, Number 3 • Viewpoints

Video. Supplemental Digital Content 1 shows pertinent clinical and intraoperative findings demonstrating radial arteriovenous fistula. This video demonstrates duplex ultrasound findings, intraoperative dissection, and gross specimen following resection. http://links. lww.com/PRS/B73. © W. Thomas McClellan, MD, FACS. Correspondence to Dr. McClellan Division of Plastic Surgery West Virginia University 1085 Van Vorrhis Road, Suite 350 Morgantown, W.Va. 26505 [email protected]

DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. REFERENCES 1. Kwac MS, Yoon SJ,Oh SJ, Jeon DW, Kim DH, Yang JY. A rare case of radial arteriovenous fistula after coronary angiography. Korean Circ J. 2010;40:677–679. 2. Goldberg A, Tsipis A, Rosenfeld I. Arteriovenous fistula after cardiac catheterization from a radial approach. Isr Med Assoc J. 2013;15:381–382. 3. Lee MS, Wolfe M, Stone GW. Transradial versus transfemoral percutaneous coronary intervention in acute coronary syndrome: Re-evaluation of the current body of evidence. JACC Cardiovasc Interv. 2013;6:1149–1152. 4. Perings SM, Kelm M, Jax T, Strauer BE. A prospective study on incidence and risk factors of arteriovenous fistulae following transfemoral cardiac catheterization. Int J Cardiol. 2003;88:223–228.

Collagenase Clostridium histolyticum Injection for Plantar Fibromatosis (Ledderhose Disease) Sir: n February of 2010, collagenase Clostridium histolyticum injection was approved by the U.S. Food and Drug Administration for treatment of palmar fibromatosis (Dupuytren contractures) in patients with a palpable cord. In December of 2013, it was approved by the U.S. Food and Drug Administration for the treatment of penile fibromatosis (Peyronie disease) in adult men with a palpable plaque

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and a curvature deformity of 30 degrees or greater on erection. Dupuytren and Peyronie disease are considered by many to be systemic manifestations of a common progressive fibrotic process that also includes plantar fibromatosis (Ledderhose disease).1,2 There has been substantial evidence in the literature supporting the use of collagenase C. histolyticum for both Dupuytren contracture3 and Peyronie disease.4 However, it was for plantar fibromatosis (Ledderhose disease) has not been previously investigated. This report contains the first known use of collagenase C. histolyticum injection for plantar fibromatosis. A 72-year-old Caucasian man presented with bilateral plantar pain on ambulation. On examination, the patient had a nodular thickening of the mid-plantar surface proximal to the great toe without flexion contracture bilaterally (Figs.  1 and 2). He had previously undergone a left partial fasciectomy with recurrence of his symptoms; conservative management and steroid injections were also previously attempted without success. The patient was noted to have Dupuytren flexion contractures of bilateral palms, but he did not seek treatment for his hands because they did not cause him pain or substantial functional problems. Considering his prior failed treatments and lack of desire for further surgery, the patient wished to attempt collagenase C. histolyticum injection as an off-label use. Each plantar nodule was injected with XIAFLEX (Auxilium Pharmaceuticals, Inc., Malvern, Pa.) at the standard dosage for a metacarpophalangeal joint (0.58  mg in 0.25  ml of reconstituted solution). The patient was injected on three separate occasions with a greater than 1-month interval between injections. Passive plantar extension to disrupt the fibrotic process could not be performed 24 hours after each treatment in a fashion analogous to that for palmar cords because of the lack of a palpable

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Radial arteriovenous fistula following percutaneous coronary intervention: a rare case.

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