Conventional angiography or CT angiography (GE Innova flat panel Model 2329766 or Siemens http://www.selleckchem.com/products/Cisplatin.html Multistar TOP image intensifier model 03135584) was obtained preoperatively to characterize the residual vascular architecture, often distorted both by initial injury and subsequent surgery. Angiography was also used to identify suitable vessels for allograft anastomosis to ensure sufficient vascular supply. Imaging was also performed to exclude subclinical systemic disease that could contraindicate the use of long-term immunosuppressive therapy. 1.5 Tesla MRI of the hips was performed on all patients to excluded preexisting avascular necrosis. Abdominal ultrasound was used to exclude subclinical abdominal pathology, and maxillofacial radiographs were requested to exclude significant sinus disease (Table 1).

Table 1 Presurgical imaging evaluation in the accepted patients. 2.2. Postsurgical Work-Up Immediate postsurgical surveillance consisted primarily of radiography of the affected arm. This was followed by sequential follow-up radiographs at 1, 3, 9, and 12 months, and yearly, to monitor bone healing. CT and MRI were again used to describe any complication noted either radiographically or physically. Repeated angiography was also performed if clinical symptoms developed that suggested arterial or venous stenosis or thrombosis. Long-term surveillance consisted of routine peripheral vascular ultrasounds performed separately by the clinical service to assure continued patency of the anastomosis and distal vessels, attempting to monitor for endothelial proliferation as a possible marker of rejection.

However, as these ultrasound examinations were performed outside of the radiology department, the images were unavailable for review. 3. Results Exclusion from candidacy was based on the weighting of multiple factors, some of which were difficult to quantify retrospectively as initial consideration for qualification occurred prior to imaging evaluation. Of the subsequent 19 individuals, ten were excluded based on psychosocial criterion beyond the scope of this paper. The nine remaining underwent imaging evaluation which revealed a combination of the below findings (Table 2). Table 2 Summary of findings as detected on imaging. 3.1. Musculoskeletal Presurgical Work-Up All remaining individuals underwent radiography of their injured extremities (Figure 1(a)).

Findings that factored into exclusion from transplant candidacy of three individuals consisted primarily of insufficient native bone and soft tissues to support an allograft (Figure 1(b)). This occurred secondary to extremity loss with maceration of the residual limb that resulted in extensive osseous compromise, fracture, and fragmentation. Two individuals were disqualified Dacomitinib when it was evident that prior surgical revisions had left insufficient viable soft tissue to support VCA, with one patient also demonstrating clinical evidence of prior skin graft failure.