Artery Anastomosis Research Articles

Probability assessment method for intrapelvic anastomoses of superior gluteal artery in humans

Aim. To develop mathematical models for determining the probability of intrapelvic anastomoses of the superior gluteal artery (SGA) in males and females. Materials and methods. Numerical data for discriminant analysis were obtained as a result of studies on 132 unidentified male (aged 40 to 60 years) and 60 female (aged 35 to 74 years) corpses. The following methods were used: preparation, morphometry, injection of blood vessels, somatotyping, mathematical modeling. Results. The length and diameter of SGA in men and women were found to be statistically significant predictor variables for the linear discriminant function. When assessing the probability of intrapelvic anastomoses of SGA using the proposed mathematical model, its accuracy was found to be 93.8 and 91.7% for men and women, respectively. The assignment of each new case to a group of males with a high or low probability of having intrapelvic anastomoses can be calculated using the following formulas: y0 = -11.174 + 1.465x1 + 5.139x2 and y1 = -31.459 + 4.101x1 + 6.436x2, in groups of females – y0 = -99.896 + 1.821x1 + 2.964x2 and y1 = -103.737 + 3.685x1 + 3.493x2. Here, x1 is the SGA diameter for each new case and x2 is the SGA length for each new case. If y0 > y1, then the man or woman belongs to the group with a low probability of having intrapelvic anastomoses of the SGA. If y0 < y1, then the people belong to a group with a high probability of having similar intrapelvic collaterals. Conclusion. The developed mathematical models can be used to predict the presence or absence of intrapelvic anastomoses of SGA in males and females with sufficiently high accuracy.

Comparison of early postoperative left ventricular function with 3d ef and strain measurements according to graft selection

BackgroundGraft choices other than left anterior descending artery (LAD)–internal thoracic artery (ITA) anastomosis in coronary artery bypass grafting (CABG) surgery are still controversial. Although 2-dimensional transthoracic echocardiography (2D TTE) is still the most commonly used method, more is needed to diagnose myocardial dysfunction. Ventricular strain values obtained by speckle tracking echocardiography (STE) or tissue Doppler imaging (TDI) methods can much better detect subclinical changes. This study aims to detect early postoperative myocardial function changes compared to single ITA/Bilateral Internal Thoracic Artery (BITA) use by measuring 3-dimensional ejection fraction (3D EF) and ventricular strain values and comparing them according to graft preference.MethodsThe study included 35 isolated CABG patients. All patients underwent on-pump CABG via sternotomy. The patients were divided into two groups using single ITA and BITA. Preoperative and postoperative 1st-week 3D EF and ventricular strain values of the patients were calculated using semi-automatic software. The recorded data were compared and evaluated between the two groups.ResultsOf The 35 patients participating in the study, 74.3% (n = 26) were male, 25.7% (n = 9) were female, and their average age was 62.7 ± 7.9 years. Preoperative 3D EF values of the patients were 54.4 ± 8.3% and postoperative 49.5 ± 8.2%. The mean preoperative Apical Long Axis Longitudinal Strain (APLAX LS) was calculated as − 16.2 ± 5.0%, 4 Chambers Longitudinal Strain (4CH LS)–16.8 ± 4.6%, 2 Chambers Longitudinal Strain (2CH LS) − 17.0 ± 4.9%, and Global Longitudinal Ventricular Strain (GLVS) − 16.7 ± 4.2%. Postoperative strain values were measured as − 15.1 ± 4.8%, − 14.7 ± 4.9%, − 14.6 ± 5.6% and − 14.8 ± 4.6%, respectively. When the groups were evaluated within themselves, the mean preoperative 3D EF of the patients in the single ITA group was 52.5 ± 8.8%, while the postoperative mean was 47.7 ± 6.0%. In the BITA group, preoperative 3D EF was 56.3 ± 7.5 and postoperative 51.4 ± 9.8. A decrease in strain values was detected in all groups except APLAX planes.ConclusionsIn our study, no statistically significant difference was observed in terms of myocardial function changes according to the use of ITA/BITA. However, the decline in postoperative strain values of patients in the BITA group was more remarkable, and it was thought that this may be due to prolonged aortic cross clamp (CC) and cardiopulmonary bypass (CPB) times.

Digital Arterial Anastomosis as an Outpatient Surgery

Background: In incomplete amputation with a skin bridge, patency of the artery indicates digit survival if sufficient venous return is secured. This study aimed to investigate the effectiveness of digital arterial repair on an outpatient basis without using intravenous anticoagulants. Methods: We identified a total of 34 patients (34 digits) who underwent arterial repair for single vascular bundle injury between January 2000 and December 2022 on an outpatient basis. The following information were obtained from the patients’ medical records: sex, age, comorbidities, active smoking status, number of affected digits, level of amputation, type of the fracture type, mechanism of injury, arterial diameter, needle used, requirement of vein graft and the outcome. Results: Only a few fingertip injuries and severe injuries were included. Arterial patency was achieved in most patients after repair of an outpatient basis. Conclusion: Outpatient arterial repair may be acceptable under inevitable circumstances or to cater to patients’ preferences, when the injury is neither on the fingertip nor severe. Background: In incomplete amputation with a skin bridge, patency of the artery indicates digit survival if sufficient venous return is secured. This study aimed to investigate the effectiveness of digital arterial repair on an outpatient basis without using intravenous anticoagulants. Methods: We identified a total of 34 patients (34 digits) who underwent arterial repair for single vascular bundle injury between January 2000 and December 2022 on an outpatient basis. The following information were obtained from the patients’ medical records: sex, age, comorbidities, active smoking status, number of affected digits, level of amputation, type of the fracture type, mechanism of injury, arterial diameter, needle used, requirement of vein graft and the outcome. Results: Only a few fingertip injuries and severe injuries were included. Arterial patency was achieved in most patients after repair of an outpatient basis. Conclusion: Outpatient arterial repair may be acceptable under inevitable circumstances or to cater to patients’ preferences, when the injury is neither on the fingertip nor severe.

Cervical heterotopic heart transplantation in mice using a novel suture technique

BackgroundVascularized transplantation models in mice are critical to understand mechanisms that mediate rejection and to develop new therapeutics. Standard abdominal heterotopic heart transplantation techniques employ an end-to-side suture technique and are the workhouse of transplant immunology research laboratories. Recently, cervical heterotopic heart transplantation in mice has emerged as an alternative due to several advantages but is conventionally performed by suture or cuff techniques in an end-to-end fashion. Therefore, we introduce an end-to-side anastomosis technique. MethodsThe donor pulmonary artery is end-to-side anastomosed to the recipient right external jugular vein, using a continuous 10-0 nylon suture. Vascular suturing is accomplished inside the vessel on the posterior wall, and then outside the vessel on the anterior wall. Finally, the donor ascending aorta is end-to-side anastomosed to the recipient common carotid artery with an identical suture technique. ResultsThe median times for the donor heart harvest, recipient preparation, anastomoses of the pulmonary artery to the external jugular vein, and the ascending aorta to the common carotid artery were 12, 10, 12 and 11 min, respectively. The survival rate was 100% (n=20). ConclusionsWe provide a detailed description of how to perform end-to-side anastomoses using a suture technique in the mouse cervical heart transplantation model. This procedure reconstitutes coronary blood flow in the heart graft with minimal interruption to recipient anatomy and provides an experimental platform to study transplant immunology.

The Occurrence of Senescence in the Arteriovenous Fistula in the Rat.

Maturational failure of dialysis arteriovenous fistulas (AVFs) not uncommonly occurs and is of considerable and timely importance. Our prior studies demonstrate that senescence, a phenotypic process that promotes vascular and other diseases, occurs in the murine AVF. In the present study, we examined whether senescence also occurs in the rat AVF model and the effect of compounds that inhibit or accelerate senescence. The rat AVF was created in the femoral vessels by an end vein-side artery anastomosis. We assessed in the AVF the expression of critical drivers of senescence, specifically, the cell cycle inhibitors p16Ink4a and p21Cip1, and such indices of a senescence phenotype as senescence-associated β-galactosidase (SA-β-gal) activity, SA-β-gal staining, and a senescence-associated secretory phenotype (SASP). We examined the effects of compounds that retard or accelerate senescence on AVF blood flow. The AVF evinced upregulation of p16Ink4a and p21Cip1 when assessed 3 days after AVF creation. The AVF also demonstrated increased SA-β-gal activity in the artery and vein; staining for SA-β-gal in the AVF artery, anastomosis, and vein; and a prominent SASP. Fisetin, an established senolytic that is protective in other models of vascular injury, when administered for 3 weeks, increased AVF blood flow and outward remodeling. Hemin, when administered for 3 weeks, decreased AVF blood flow. We demonstrate that hemin is a novel inducer of a senescence phenotype in endothelial cells, as reflected by several senescence indices. However, when administered relatively acutely (for 5 days) hemin increased AVF blood flow via HO-dependent mechanisms, as the latter was entirely prevented by a competitive inhibitor of HO activity. The rat AVF exhibits senescence within 3 days of its creation. Chronic administration of a senolytic compound (fisetin) increases AVF blood flow, whereas chronic administration of a pro-senescence compound (hemin) decreases AVF blood flow.

Intraoperative Complications as Predictors of Flap Failure in Autologous Breast Reconstruction.

Intraoperative microvascular complications in autologous breast reconstruction significantly increase the risk of post-operative complications. No study has identified which specific intraoperative complications contribute to partial or total flap loss. A retrospective chart review of microsurgical breast reconstructions by five surgeons between 2009-2020 analyzed operative variables and patient outcomes, with complications determined from the operative report. Flap loss rates were compared between cases with and without intraoperative complications. Statistical analysis was performed using Fischer exact and t-tests for discrete and continuous variables, respectively. Intraoperative complications were analyzed for 1465 autologous breast flaps performed in 916 patients. Early partial flap loss was predicted by arterial anastomosis revision (2.90% vs 0.44%, p=.03) and alternate venous outflow (14.29% vs 0.41%, p=.002), with no association with intraoperative thrombosis, venous revision, or difficult recipient or flap dissection. In comparison, early total flap loss was predicted by intraoperative arterial revision (5.80% vs 0.51%, p=.001), venous revision (5.45% vs 0.57%, p=.007), intraoperative thrombosis (12.12% vs 0.49%, p<.001), and difficult flap dissection (2.91% vs 0.59%, p=.04). Difficult flap dissection was the only intraoperative variable associated with late partial flap loss (6.80% vs 1.69%, p=.004). Late total flap loss only occurred in 6/1465 flaps, the sole association being difficult recipient vessel dissection (2.78% vs 0.29%, p=.03). Post-operative arterial and venous compromise occurred in 1.10% (13/1187) and 2.53% (30/1187) of cases with no intraoperative complications, respectively, compared to 3.2% (9/278, p=0.02) and 6.12% (17/278, p=0.002) in cases with an intraoperative complication. Alternate venous outflow predicts early partial flap loss, while intraoperative thrombosis, and arterial and venous revision predict early total loss. Difficult flap dissection was associated with early total and late partial flap loss, while difficult recipient vessel dissection was associated with late total flap loss.

Safe Endovascular Recanalization of Internal Carotid Artery Occlusion Using Retrograde Aspiration Angiography

ObjectsCerebral infarction, resulting from acute internal carotid artery (ICA) occlusion, typically manifests with a wide ischemic area and severe symptoms. Mechanical thrombectomy proves effective within 24 hours of disease onset and in less ischemic infarction core. However, in cases with well-developed collateral flow and mild symptoms, conservative treatment is initially selected. If symptoms worsen or ipsilateral hemisphere perfusion decreases, superficial temporal artery (STA) – middle cerebral artery (MCA) anastomosis is considered. Revascularization therapy may also be effective. Contralateral angiography allows for ipsilateral blood flow verification once complete revascularization is achieved, albeit with potential treatment-related complications. Here, we describe retrograde angiography using an intermediate catheter (IMC) and contralateral contrast injection to achieve safer revascularization. MethodsWe present ten acute ICA occlusion cases caused by thromboembolism, arteriosclerosis, carotid artery stent occlusion, or embolic stroke of undetermined source. Employing bilateral femoral artery puncture, one catheter was guided to the occluded ICA, while another was positioned for diagnostic purposes in the contralateral ICA or vertebral artery. The IMC was navigated through the occluded vessel, with contralateral imaging performed during aspiration. The catheter was gradually retracted to confirm the extent of occlusion and recognize recanalization. ResultsRecanalization was successfully achieved in all cases. Symptomatic ischemic complication and hyperperfuison was not seen in all cases. No cases were decreased modified Rankin scale after treatment. ConclusionAdvancements in IMC technology facilitate distal catheter guidance to the ICA, even in proximal occlusion. Combining this technique with contralateral imaging allows us to confirm the extent of occlusion and recanalization status without antegrade imaging, making recanalization therapy safer.

Measuring Peri-Anastomotic Pressure to Identify Patients at High-Risk for Dialysis Associated Steal Syndrome

Dialysis Access-associated Steal Syndrome (DASS) is one of the most serious complications of hemoaccess surgery. Treatment algorithms involve significant morbidity; a tool to reliably identify patients at risk who could benefit from interventions at time of operation would be useful. We present a strategy of using peri-anastomotic pressure (PAP) measurement to identify patients who may be at high risk of developing DASS. Patients who underwent dialysis access creation between January 1, 2018 and September 30, 2022 at our institution were reviewed. Beginning October 2019, we developed a strategy of measuring systolic pressure at the arterial anastomosis intra-operatively. A ratio of this value compared to the systemic systolic pressure was calculated. In patients believed to be high-risk for developing DASS based on clinical findings, selective banding of the access was performed intra-operatively to augment distal perfusion. Of 857 total patients, 36 (4.2%) developed clinically significant DASS, defined as requiring operative treatment, either intraoperatively or during follow-up (mean, 76 days; range, 0-602 days). DASS was more common for femoral-based accesses (6/12, 46.2%) compared to upper extremity accesses (30/840, 3.6%, p < 0.001). No patients who underwent radiocephalic arteriovenous fistula (AVF) or infraclavicular axillary arteriovenous graft construction developed DASS. There was no difference in DASS for upper extremity AVFs (20/576, 3.47%) vs. AV grafts (10/264, 3.79%, p = 0.82). 216 patients had PAP measured intra-operatively. Fourteen (6.5%) of these 216 patients developed DASS requiring intervention in follow-up. The mean PAP ratio of these 14 patients was 0.395 vs. 0.557 for the 202 patients who did not [CI 0.07-0.25, p = 0.001]. Seventeen patients who had low PAP ratio with poor distal perfusion underwent intra-operative banding, which improved mean PAP ratios from a mean of 0.33 to 0.58. Despite banding, 3 of these 17 (17.6%) patients in this high-risk subgroup went on to develop DASS postoperatively. The calculated mean PAP ratio in patients who either developed DASS post-operatively or underwent prophylactic banding intra-operatively was 0.37, which was significantly lower than the mean ratio of 0.57 in the control group (p = 0.001). Low PAP ratios (less than 0.50) identified patients at elevated risk for DASS, but prophylactic banding did not always prevent the occurrence of DASS in select patients. Because steal is a dynamic phenomenon, intraoperative conditions are not always going to reflect later adaptation. Nonetheless, PAP measurement may identify a subgroup warranting procedural modification or closer postoperative physiologic monitoring.

Morphological rationale for surgical treatment of patients with true splenic artery aneurysm

Aim. To study the morphological features of the wall structure of the splenic artery aneurysm in order to identify the safest and most effective method of surgical treatment.Materials and methods. From 2020 to 2023, 43 patients underwent surgery for true splenic artery aneurysm. Interventions involved laparoscopic clipping of aneurysm branches, laparoscopic resection of aneurysm, laparoscopic splenectomy, and resection of giant splenic artery aneurysm. A clinical and morphological study of 16 slides of splenic artery aneurysm was performed. The aneurysm wall and the adjacent wall of the splenic artery without macroscopic signs of lumen dilatation for 1 cm from the aneurysmal dilatation were examined.Results. Microscopic study revealed fragments of loose, edematous wall of large elastic arteries with atherosclerosis, atheromatosis and calcification. Atherosclerotic plaques were observed in the intima; calcium deposits were detected in 81.25% of slides, and defects in elastic fibers – in all slides. The elastic membrane was thinned or had a discontinuous structure. Morphological changes in the wall of the splenic artery persisted up to 1.0 ± 0.2 cm proximal and distal to the aneurysm.Conclusion. Taking into account the revealed features of the morphological structure of the aneurysm, the formation of an end-to-end vascular anastomosis of the splenic artery, clipping or suturing of the aneurysm neck pose a significant risk of aneurysm recurrence. Laparoscopic clipping of splenic artery aneurysm branches at a distance of &gt;1.5 cm from the edges of the aneurysm becomes the operation of choice for patients in this category.

Arterial anastomosis in LDLT: techniques and risks.

Reconstructing the hepatic artery in adult living donor liver transplantation is technically challenging, with complications leading to significant morbidity and mortality. Early arterial thrombosis can result in a mortality rate up to 50%, often necessitating re-transplantation. The most common techniques for arterial anastomosis include end-to-end reconstruction with interrupted or continuous sutures, either using magnifying loupes or a microscope. Although microscopes provide enhanced precision, they do not significantly reduce early thrombosis rates compared to loupes but increase surgical time. Overall, surgeons can achieve early thrombosis rates below 1% with experience and evolving techniques.

Cadaveric Feasibility of Robotic-Assisted Radial Artery-Internal Carotid Artery-Middle Cerebral Artery Anastomosis for Neurovascular Surgery.

To the best of our knowledge, this is the first reported cadaveric feasibility study of leader-follower type robotic-assisted middle cerebral artery (MCA)-radial artery-internal carotid artery anastomosis in the neurovascular surgery field using the da Vinci Xi system (da Vinci Surgical System; Intuitive Surgical, Inc.). Vascular suturing is a necessary skill in neurosurgery; however, the learning curve for deep and high-flow bypasses is severely low. Thus, robot-assisted surgery has been introduced. Here, we describe the surgical workflow adaptations of vascular anastomosis using the da Vinci system to assess the feasibility of robot-assisted anastomoses of the radial and middle cerebral arteries. Two fresh cadaver heads were studied using the da Vinci Xi Surgical System with 0° and 30° stereoscopic endoscopes to visualize the neuroanatomy. The da Vinci Xi Surgical System was used throughout the anastomosis of the MCA and intracarotid artery. The optic nerve, optic chiasm, carotid artery, and oculomotor nerve were visualized using standard microdissection techniques. The Sylvian fissure was exposed from the proximal Sylvian membrane to the distal MCA. Using black diamond microforceps and Potts scissors, suturing was achieved on the radial artery-middle cerebral artery using 8-0 Prolene and on the radial artery-internal carotid artery using 7-0 Prolene. A bypass of the MCA-radial artery-internal carotid artery can be achieved using the da Vinci Xi Surgical System in cadaver models. This system provides experts and less experienced neurosurgeons with stable bypass techniques for both superficial and deep-seated arteries. However, further studies are needed to evaluate the safety and benefits of the da Vinci Xi Surgical System for bypass procedures.

Advances in Reconstructive Robotic Microsurgery in the Extremity.

Robotic surgery has emerged as a promising technique for reconstructive procedures, offering potential advantages across various surgical fields. Following initial case reports on the use of the Symani Surgical System (Medical Microinstruments, S.p.A) for microsurgical anastomosis, the authors evaluated its full potential in extremity reconstruction. They conducted a retrospective analysis of patients with soft tissue defects of the upper and lower extremities treated between February 2022 and May 2024. Each patient underwent soft tissue reconstruction with free tissue transfer with microsurgical anastomosis performed using the Symani Surgical System. The study included 7 male patients and 1 female patient, aged between 19 and 71 years (mean age: 50.6y). The most used recipient vessels were the anterior tibial artery and vein (37.5%). The preferred anastomotic technique was end-to-side in arterial anastomoses (6/8). All arterial anastomoses were performed using the Symani Surgical System. The mean anastomosis time was 33.2±5.8 minutes. One out of 8 patients required surgical revision outside of the anastomosis. The authors' findings suggest that using the Symani Surgical System for microanastomosis in extremity reconstruction is a safe and effective approach, leading to satisfactory outcomes in different anatomic regions. The system allows for the successful execution of various anastomosis techniques, including end-to-end and end-to-side connections, using single interrupted or running sutures, which enhances its versatility in complex reconstructive procedures. The benefits of robotic assistance in terms of precision and ergonomics are promising for the future of reconstructive microsurgery.

Artery Grafting for Arterial Anastomoses in Head and Neck Free Tissue Transfer Reconstruction.

Vessel grafting is an important technique in head and neck free tissue transfer (FTT) reconstruction when a tension-free anastomosis is not otherwise feasible. To our knowledge, there are limited data regarding interposition artery grafts for arterial anastomoses in head and neck reconstruction. Here, we present a multi-institutional cohort of arterial interposition grafts for FTT reconstruction for head and neck defects. A retrospective review was conducted at four tertiary care institutions for patients who underwent FTT reconstruction for head and neck defects which utilized an interposition artery graft for the arterial anastomosis. Charts were reviewed for type and length of artery grafts harvested, surgical indication, indication for artery graft, types of flaps harvested, and various preoperative characteristics (including history of radiation or previous FTT reconstruction surgery). Postoperative complications within postoperative day 30 were measured and reported. Nine patients met inclusion criteria. The lateral circumflex femoral artery (either transverse or descending branches) (n = 3) and facial artery (n = 3) were the most commonly harvested arteries. The scalp (n = 5) was the most common primary defect site. Seven grafts were harvested initially and in a planned fashion, while two were harvested as salvage techniques (either for flap salvage or vein graft failure). In planned grafts, arteries were the preferred interposition grafting method due to either size match preferences (n = 4) or similarities in wall thickness (n = 3) between graft and recipient artery. There were no reported cases of unplanned readmission, postoperative hematoma, fistula formation, wound infection, or donor site morbidities. Two patients required unplanned return to the operating room for flap compromise, both of which ultimately resulted in flap failure secondary to clot formation at both arterial and venous anastomoses. When arterial pedicle length is insufficient, interposition artery grafting is both a feasible and viable technique to achieve tension-free arterial anastomoses for select cases of highly complex head and neck free tissue reconstruction.

A novel arterial coupler with non-return snap-fit connection approach optimized arterial end-to-end anastomotic technique: An experimental study

PurposeHand-sewn anastomosis as the gold standard of vascular anastomosis cannot fully meet the requirements of vascular anastomosis in speed and quality. Various vascular couplers have been developed to ameliorate this situation. Most of them are mainly used for venous anastomosis rather than arterial anastomosis, even though it is generally acknowledged that in almost all operations involving vascular reconstruction, it is the arteries that need to be anastomosed faster and more accurately and not the veins. A dedicated device is needed for creating arterial anastomosis in an easy, timesaving, less damaging but reliable procedure. Therefore, we plan to develop a novel arterial coupler device and test pre-clinical safety and effectiveness. MethodsIn this cohort study, the rationality of this novel arterial coupler was preliminarily tested by finite element analysis before it was manufactured. Several factors restrict the use of vascular couplers in arterial anastomosis, such as arterial eversion, fixation, etc. The manufactured arterial couplers underwent in vitro and in vivo experiments. In vitro, isolated arteries of beagles were anastomosed with the assistance of an arterial coupler, and the anastomosed arteries were evaluated through anti-traction tests. In animal experiments, the bilateral femoral arteries of 5 beagles served as a control group. After dissection, the femoral artery on one side was randomly selected to be anastomosed with a quick arterial coupler (QAC) (QAC group), and the femoral artery on the other side was anastomosed by the same person using an end-to-end suture technique with a 6-0 Prolene suture (suture group). The bilateral femoral arteries of 5 beagles were used for coupler-assisted anastomosis and hand-sewn anastomosis in vivo, respectively. Success rate, blood loss, anastomotic time, clamp time, total operation time, and patency rate were recorded. The patency of anastomosed arteries was assessed using vascular Doppler ultrasound, electromagnetic flowmeter, and pathological examination (6 weeks after surgery). ResultsAs a novel arterial coupler, QAC was successfully designed and manufactured by using poly lactic-co-glycolic acid raw materials and 3-dimensions printing technology. Its rationality was preliminarily tested through finite element analysis and related mechanical analysis methods. The isolated arteries were successfully anastomosed with the assistance of QAC in vitro testing, which showed good anti-traction properties. In animal studies, QAC-assisted arterial anastomosis has superior profiles compared to hand-sewn anastomosis in anastomotic time (7.80 ± 1.41 vs. 16.38 ± 1.04 min), clamp time (8.80 ± 1.41 vs. 14.14 ± 1.57 min), and total operation time (46.64 ± 2.38 vs. 51.96 ± 3.65 min). The results of electromagnetic flowmeter, vascular Doppler ultrasound, and pathological examination showed that QAC-assisted anastomotic arteries were superior to hand-sewn arteries in terms of postoperative blood flow (16.86 ± 3.93 vs. 10.36 ± 0.92 mL/min) and vascular patency in 6 weeks after surgery. ConclusionQAC is a well-designed and easily maneuverable device specialized for end-to-end arterial anastomosis. Application of this device may decrease thermal ischemia time and improve the patency of anastomotic arteries, thus, improving outcomes.

Embolize, supercharge, resect: Embolization to enhance hepatic vascularization prior to en-bloc pancreas and arterial resection

IntroductionEmbolization could increase the resectability of pancreatic tumors by supercharging visceral arterial perfusion prior to pancreatic surgery with arterial en-bloc resection. Its indications, however, are controversial. MethodsWe retrospectively analyzed the results of a single-center database of patients undergoing pancreatic surgery with arterial resection (AR) after preoperative arterial embolization (PAE) to increase hepatic vascular flow and spare arterial reconstruction. ResultsPAE was planned in 15 patients with arterial involvement due to pancreatic tumors. Three patients were excluded due to the finding of irresectable disease during surgery. Twelve cases were resected because of pancreatic cancer (10), distal cholangiocarcinoma (1), and pancreatic neuroendocrine tumor (1). Arterial involvement in these cases required embolization of the substitute right hepatic artery (RHA) (5), left hepatic artery (1), and common hepatic artery (CHA) (6) to enhance liver vascularization. Two patients presented migration of the vascular plug after PAE. Six pancreatoduodenectomies and 6 distal pancreatectomies were performed, the latter associated with en-bloc celiac trunk and CHA resection. R0 was achieved in 7 out of 12 patients, and pathological vascular involvement was confirmed in 8. Postoperative complications included one patient who developed gastric ischemia and underwent gastrectomy, and one patient who underwent reoperation for acute cholecystitis with liver abscesses. ConclusionPreoperative arterial embolization before pancreatic surgery with hepatic arterial resection enables surgeons to precondition hepatic vascularization and prevent hepatic ischemia. In addition, this avoids having to perform arterial anastomosis in the presence of pancreatic suture.

Three-dimensional microscope skill acquisition: A randomised controlled study comparing two-dimensional laboratory microscope training, video gaming and virtual reality gaming

IntroductionFine microsurgical motor skill acquisition can be challenging. With increasing technological innovation the method of microsurgical skills acquisition may change. Studies show that laboratory-based microsurgical training programs on a 2D microscope significantly improves novice’s microsurgical skill acquisition. However, are these skills transferable to a 3D microscope or is gaming agility more important? We present a randomised control trial of three interventions, namely laboratory tabletop microscope training (LM), high-fidelity video gaming (Sony PlayStation 4 console) (VG) and high-fidelity virtual reality gaming (Sony PlayStation VR console) (VR) versus a control group. MethodsForty novice medical students were block randomised to four groups: control (no intervention) n=10, LM n=10, VG n=10 and VR n=10. Participants performed chicken femoral artery anastomosis using the Aesculap Aeos® 3D microscope platform at baseline and again after intervention. Performance was evaluated using a modified structured assessment of microsurgery skills (mSAMS) score, time taken to complete anastomosis and time for suture placement by two blinded independent assessors. ResultNo statistically significant difference was noted between the groups at baseline. There was a statistically significant improvement in the LM arm between baseline and post-training for mSAMS score and time for suture placement. In the VG, VR and control groups no statistically significant difference was observed. ConclusionOur study demonstrates that during early microsurgical training, an intense laboratory-based microsurgical training program significantly improves novice’s anastomotic performance on a 2D microscope, and these skills are transferable when a 3D anastomosis is carried out. However, focussed gaming had no significant effect, and the results were akin to the non-intervention group.

Liver and pancreas transplantation in adult donor and recipients with situs inversus totalis: a case series and review of the literature

BackgroundSitus inversus totalis is a rare congenital anomaly characterized by a mirror-image orientation of abdominal, and in some cases, thoracic organs. Here, we report our situs inversus totalis transplantation experience and further review liver transplantations in adult recipients and donors with situs inversus totalis.Case presentationWe describe three cases with situs inversus totalis. The first case was liver transplantation in a recipient (a 61-year-old Iranian man) with situs inversus totalis, the second was a liver transplantation from a donor (a 52-year-old Iranian woman) with situs inversus totalis, and finally, for the first time, a simultaneous pancreas and kidney transplantation in a recipient (a 26-year-old Iranian man) with situs inversus totalis. In patient one, hepatectomy could be performed according to the standard method and on the basis of preoperative studies. Hepatic vein and arterial anastomosis were performed as in every other patient without situs inversus totalis. To prevent biliary complications, a Roux-en-Y hepaticojejunostomy was performed. In patient two, implantation time, suprahepatic vein, portal vein, arterial, and biliary reconstruction could be done as in any other case without situs inversus totalis. Plication of the right-sided diaphragm and fixation of the falciform ligament was done for our patient. In patient three, systemic drainage was preferred to portal flow for establishing the outflow drainage of the pancreas compared with otherwise normal patients.ConclusionAlthough situs inversus totalis is a rare condition, our reported techniques are suitable, considering advantages such as easier accessibility, more acceptable placement of the implanted organs regarding vascular variations, and the appropriate location of the allograft in the proximity of other organs.

Fully Telemetric Robotic Microsurgery: Clinical Experience With 23 Cases.

Recently, there is an ongoing trend in plastic surgery with robotic-assisted microsurgery and supermicrosurgery devices being developed. Combining a telemetrically controlled robotic microscope with an also telemetrically controlled microsurgery robot unlocks synergistic effects with complete disconnection of the operating surgeon from the operating field. Here, we report the first clinical free flap reconstructions using this setup. Twenty-three surgeries were performed with the combined remote approach using the Symani Surgical System and the RoboticScope in open microsurgery procedures. Anastomosis time and ischemia time were recorded. The surgical performance for anastomoses was assessed using the modified Structured Assessment of Microsurgical Skills (SAMS) score. Subjective satisfaction was evaluated by the surgeons in comparison with conventional microsurgery. To evaluate the learning curve, the senior authors first four (first group) and last four (last group) procedures were compared. Overall, flap survival was 95.7%. The average arterial anastomosis time was 36.7 ± 10.9 min. Total time of surgery was 277.7 ± 63.8 min, and ischemia time was 100.6 ± 24.9 min. Most SAMS score parameters were significantly higher in the last group of surgical procedures compared with the first operations. Subjective satisfaction was equal or better with the combined robotic-assisted approach in most categories. Our data demonstrates safety and feasibility of the use of a combined remote approach. Robotic systems for microsurgical procedures may hold promising potential for improvement of surgical quality and open up new frontiers in microsurgery.

Prognostic Prediction of Multiterritory Flap: A Preliminary Clinical Study on the Classification of Priority Developing Artery and Arterial Anastomosis Utilizing Indocyanine Green Angiography.

Congestion and necrosis are frequent complications in multiterritory flaps. Indocyanine green angiography (ICGA) is a commonly utilized tool for evaluating blood flow and perforator location within the flap; however, there is currently no existing research investigating its potential to predict flap prognosis before surgery. The forehead skin of 50 surgical patients was assessed using preoperative ICGA, enabling observation and classification of the priority developing artery and arterial anastomosis among adjacent arterial perfusion territories during the arterial phase. Subsequently, 5 clinical cases of forehead flap transfer were studied to validate the classification method. First, the priority developing artery can be classified into 4 types and 5 subtypes, encompassing type Ⅰa: Bilateral ST-As equalization type (9/50), type Ⅰb: unilateral ST-A dominance type (11/50), type II: SOT-As dominance type (14/50), type III: unilateral ST-A plus SOT-A dominance type (6/50), and type IV: bilateral ST-As plus SOT-As equilibrium type (10/50). Second, arterial anastomosis can be divided into 5 types: type I: complete choke anastomosis type (13/50), type II: complete true anastomosis type (7/50), type III: central choke anastomosis type (10/50), type IV: bilateral choke anastomosis type (8/50), and type V: unilateral choke anastomosis type (12/50). Finally, the clinical flap outcomes showed that the ICGA classification could serve as a good prognostic indicator. The hemodynamic classification of priority developing artery and arterial anastomosis employed by ICGA has the potential to predict flap prognosis and offer valuable insights for preoperative design and perioperative treatment strategies. More sample size is needed to optimize and validate this classification.

Effectiveness of 1α-25-dihydroxyvitamin D3 active substance on anastomosis safety in the rat femoral artery end-to-end anastomosis experimental model: Macroscopic and histological analyses

In inflammatory conditions, macrophage dominance affects the degree of inflammation. We assessed the effects of the active vitamin D (calcitriol) on inflammatory processes and macrophage dominance and aimed to determine the potential positive macroscopical and histological effects in the supermicrosurgical arterial anastomosis model of rats. Forty rats were divided into five groups: control surgery (Group 1), surgery with preoperative (Group 2), postoperative (Group 3) and peroperative (Group 4) systemic calcitriol, and surgery with local calcitriol (Group 5). Eighty femoral artery anastomoses were planned in both legs of rats. Systemic calcitriol was administered intraperitoneally to the relevant groups daily. Preoperative vessel diameter measurements were taken before anastomosis. Three weeks postsurgery, postoperative vessel diameter measurements were taken, anastomosis patency was assessed, and vascular segments were collected for histological examination, which included assessment of M1 and M2 macrophage depolarization, leucocyte infiltration, intima–media ratio, and luminal gap scoring. Systemic calcitriol administration (pre-, post-, or perioperative) significantly improved vessel diameter (p < 0.001); there was no significant difference among Groups 2–4. Histological findings revealed that Groups 3 and 4 had lower intima–media ratios (p < 0.05 and p < 0.01), higher M2-M1macrophage ratios (p < 0.01 and p < 0.001), and lower leucocyte infiltration (p < 0.05, p < 0.01, and p < 0.001). Local calcitriol administration had no vasodilatory effects or resulted in positive histological outcomes. Although the administration of calcitriol pre- and postoperatively increased vessel diameter, the latter appeared to have a more favorable impact on the histological analyses.