Louisiana Via Research Day Book 2026

Case Studies: Section 1

Case Studies: Section 1

Russel T. Wagner, OMS-I 1,2 ; Amin Kassam, MD 1 ; Jacopo Berardinelli, MD 1 ; Usman Khan, MD 1 ; Melanie Fukui, MD 1 ; Julian Bailes, MD 1 ; Sammy Khalili, MD 1 ; Mikaeel Kassam, MS2 1 ; Hannah Walsh, BS 1 ; Neil Mundi, MD 1 1 Intent Medical Group, Northwest Community Hospital, Arlington Heights, Illinois; 2 VCOM-Louisiana 29 THE “TRIMERIC” ANTEROLATERAL THIGH FREE FLAP: A NOVEL TECHNIQUE FOR THE RECONSTRUCTION OF COMPLEX CRANIO-ORBITAL AND MIDDLE SKULL BASE DEFECTS

Alex (AJ) Siebert, NREMT-P, OMS-III 1 ; Melissa Lipsmeyer, PhD 1 ; Rushton Jones, MD 2 ; Ronni Naramore, DO 3 1 VCOM-Louisiana; 2 St. Francis Medical Center – Department of Anesthesiology; 3 St. Francis Medical Center – Department of Family Medicine 30 MANAGING ANESTHESIA IN HEREDITARY HEMORRHAGIC TELANGIECTASIA: LESSONS FROM A COMPLEX CASE

Context: The anterolateral thigh (ALT) free flap is a versatile option for reconstructing complex three-dimensional defects in the head and neck region. It can be tailored for cutaneous, fasciocutaneous, musculocutaneous, or flow through configurations, depending on patient needs. Chimeric flaps, comprising distinct tissue components with a shared vascular source, enable the reconstruction of challenging defects in a single procedure by providing customized functional and aesthetic coverage. Clinical Presentation: We had a 65-year-old male with an atypical (WHO Grade II) sphenoid wing meningioma extensively infiltrating the left anterior and middle cranial base, infratemporal fossa, and masticatory region. Subsequent surgeries and necrotizing fasciitis resulted in a large skull base defect involving the middle cranial fossa and orbitozygomatic complex. Traditional methods, including multiple staged free flaps or local soft tissues, were impractical because of insufficient tissue variety and limited recipient vessels. Therefore, we extended the concept of a chimeric flap with a third component, creating a “trimeric” ALT free flap that incorporated three tissue components

vastus lateralis muscle, tensor fascia lata, and rectus femoris muscle. Each layer was nourished by perforators from the descending branch of the lateral circumflex femoral artery. This design allowed simultaneous reconstruction of the middle cranial fossa, durable dural closure, and restoration of temporalis muscle bulk in one operation. Conclusion: This represents the first successful application of a trimeric ALT flap for comprehensive skull base reconstruction, offering a novel solution for multilayer defects requiring functional and structural restoration. Surgical technique, outcomes, and implications for future skull base reconstructions are discussed.

Context/Impact: Hereditary hemorrhagic telangiectasia (HHT), once estimated to affect approximately 1 in 100,000 individuals, is now recognized to have an estimated prevalence closer to 1 in 5,000, underscoring it as a growing clinical concern for anesthesiologists due to its rise in prevalence. HHT poses unique challenges due to fragile vascular malformations, recurrent bleeding, and risk of shunting leading to hemodynamic instability. Report of Case: We present a 72-year-old male with transfusion-dependent HHT who presented with epigastric pain and new-onset hemoptysis, found to have a left-sided hydropneumothorax and an ingested foreign body. His extensive comorbidities, including end-stage renal disease, congestive heart failure, chronic obstructive pulmonary disease, and chronic anemia, compounded his risk profile. A chest tube was placed under conscious sedation, followed by total intravenous anesthesia for combined esophagogastroduodenoscopy and colonoscopy, which revealed a plastic bottle cap lodged within the distal esophagus. Through coordinated care between anesthesia and gastroenterology, gentle esophageal dilation and

retrieval was performed with minimal bleeding and stable hemodynamics.

Conclusion: This case highlights the anesthetic complexities of HHT, emphasizing pre-procedural screening for arteriovenous malformations, careful airway and hemodynamic management, readiness for blood product support, vigilant post-procedural monitoring for delayed bleeding, and interdisciplinary coordination. As awareness of HHT’s true prevalence grows, anesthesia clinicians are increasingly likely to encounter such patients, where tailored assessment and anesthetic strategies are essential to ensure patient safety and demonstrate that even high-risk patients can safely undergo complex procedures.

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2026 Research Recognition Day