Artery Anastomosis Research Articles

Intraoperative Neuromonitoring of Hypoglossal Nerves Using Transcranial and Direct Electrical Stimulation During Extracranial Internal Carotid Artery Surgery.

We explored whether the electromyogram (EMG) and the motor evoked potential (MEP) are useful for monitoring the function of the hypoglossal nerve during surgery targeting the cervical segment of the internal carotid artery. The present study included 6 patients with internal carotid arterial stenosis (1 patient underwent bilateral surgeries) and 1 patient with a cervical carotid artery aneurysm. In 5 of the 8 procedures, the EMGs were recorded. We examined whether changes in the MEP and/or EMG were capable of predicting postoperative hypoglossal nerve deficits. None of the 6 patients who underwent a total of 7 carotid endarterectomy (CEA) procedures experienced postoperative hypoglossal nerve morbidity. In 2 of the 7 procedures, the MEP disappeared or decreased significantly during CEA. In all 4 cases in which the hypoglossal nerve was directly stimulated during CEA, stable and reproducible EMGs were obtained throughout the manipulation of the internal carotid artery. Hypoglossal nerve morbidity was observed in the one case that underwent aneurysm removal and end-to-end anastomosis of the internal carotid artery. In this case, while the MEP decreased significantly during the operation, the EMG showed true-positive results and false-negative results, depending on the stimulation site. The monitoring of hypoglossal nerve function using EMG appears to be accurate if an appropriate stimulation site is selected. Hypoglossal nerve monitoring using MEP can produce false-positive results. Combined monitoring using both MEP and EMG is recommended in cases where exposure of the hypoglossal nerve is expected to be technically difficult.

A Novel Dissection Method of the Internal Mammary (Thoracic) Artery: Anastomotic Vessel of the DIEP Flap

Deep inferior epigastric perforator flaps are commonly used for breast reconstruction using autologous tissue. For such free flaps, the internal mammary artery provides stable blood flow as the recipient for anastomosis. We report a novel dissection method of the internal mammary artery. First, the perichondrium and costal cartilage of the sternocostal joint are dissected with electrocautery. Then, the incision on the perichondrium is extended along the cephalic and caudal ends. Next, this C-shaped superficial layer of perichondrium is elevated from the cartilage. The cartilage is incompletely fractured with electrocautery, with the deep layer of perichondrium intact. Then, the cartilage is completely fractured by leverage and removed. The remaining deep layer of perichondrium is incised at the costochondral junction and shifted aside, revealing the internal mammary artery. The preserved perichondrium creates a rabbet joint to protect the anastomosed artery. This method not only enables a more reliable, safer dissection of the internal mammary artery, but also allows reusage of the perichondrium as underlayment in the setting of anastomosis, and coverage for the incised rib edge, protecting the anastomosed vessels.

Effects of external bleeding and hyperbaric oxygen treatment on Tamai zone 1 replantation.

Tamai zone 1 replantation poses a challenge due to the very small size of the vascular structures; often there is no vein for anastomosis. Replantation may have to be done with only an arterial anastomosis. In our study, we aimed to evaluate the success of replantation by combining external bleeding and hyperbaric oxygen treatment (HBOT) in Tamai zone 1 replantation. Between January 2017 and October 2021, 17 finger replantation patients who underwent artery-only anastomosis due to Tamai zone 1 amputation received 20 sessions of HBOT with external bleeding after the 24th postoperative hour. Finger viability was assessed at the end of treatment. A retrospective review of outcomes was performed. Seventeen clean-cut finger amputation patients were operated on under digital block anaesthesia with a finger tourniquet. No blood transfusion was required. In one patient, complete necrosis developed and stump closure was performed. Partial necrosis was observed in three patients and healed secondarily. Replantation in the remaining patients was successful. Vein anastomosis is not always possible in fingertip replantation. In Tamai zone 1 replantation with arteryonly anastomosis, post-operative HBOT with induced external bleeding appeared to shortened the hospital stay and was associated with a high proportion of successful outcomes.

Scaphoid Arterial supply: A Review

Scaphoid, the boat-shaped carpal bone, is largely covered by articular cartilage. It has a much more complex arterial supply than previously reported, moreover, this arterial pattern has been hypothesized to lead to avascular necrosis after fracturesScaphoid blood supply has long been documented as scarce; it arises from the radial artery giving palmar and dorsal branches. There is high-grade evidence reporting two main arteries entering from the distal half of the scaphoid and middle to lower-grade evidence reporting several arteries scattered over the entire scaphoid and anastomosis of the radial artery with intercarpal arteries. Dorsal arteries are slightly larger in diameter and many more than volar ones. The scaphoid shape is associated with variations in arterial supply patterns. Scaphoid surgery preserving vascular supply is the gold standard. Scaphoid blood supply is not as poor as previously documented, as current evidence supports even proximal pole vascularization. We recommend surgery to preserve the blood supply and foster research in this area.

Surgical anatomy of the intrapelvic branches of the superior gluteal artery in people of a mesohomorphic somatotype

Objectives. To explore data on branching variants of the intrapelvic part of the superior gluteal artery in people of mesomorphic somatotype.Materials and methods. We used 48 male dead bodies (deceased aged 25 to 82) and 30 female dead bodies (deceased aged 28 to 78) whose deaths were the result of accidental causes unrelated to the pelvic organs pathology. The following methods were used to achieve the goal of the study: vascular injection, dissection, statistical processing.Results. The pattern of localization of anastomotic branches of the intrapelvic part of the superior gluteal artery (SGA) in humans of both sexes of mesomorphic somatotype was established for the first time. In men, 59.1% of all anastomotic branches of the SGA are located in the proximal third, 36.4% of anastomoses are in the middle third of this artery, and 4.5% of arterial connections are in the distal third of a. glutea superior. In women, arterial anastomoses branch from the proximal third of the intrapelvic portion of the SGA in 66.6% of cases and in the middle third of this artery in 33.3% of cases. The SGA in men of mesomorphic somatotype anastomoses more frequently than in women with the same type of build. It was found that intrathecal branches and anastomoses of the SGA in men and women of mesomorphic somatotype are predominantly localized along the proximal two thirds of this artery length. New data were obtained on the number of branches originating from a. glutea superior in the pelvic cavity, such as the lateral sacral artery (LSA), iliac-lumbar artery (ILA), obturator artery (OA), middle rectus, lower ureteric artery and rami musculares of the SGA. The SGA was found to be the most frequent source of lateral sacral artery formation in the pelvic cavity in men and women of mesomorphic somatotype.Conclusions. The patterns of branching of the intrathecal part of the SGA are presented. The results obtained are recommended to be used for endovascular occlusion of the SGA to stop bleeding from the damaged distal third of this artery.

Early Outcomes in Renal Transplantation With Routine Intraoperative Duplex Ultrasound

While intra-operative duplex ultrasound scanning can be readily performed in renal transplantation, the value of this intervention in routine practice is not established. Three hundred thirty-one consecutive single renal transplants in adult recipients underwent intraoperative scanning at implantation. Early graft losses were compared with those recorded in the ANZDATA Registry. Nine overt vascular abnormalities were corrected prior to scanning. Four further suspected venous outflow restrictions were confirmed by ultrasound and revised. Another 11 major vascular revisions were performed following intraoperative ultrasound consisting of 7 otherwise unsuspected inflow abnormalities, all corrected, and 4 anastomoses redone to reposition the graft. Thirty-two (9.7%) grafts were repositioned under ultrasound guidance to improve cortical perfusion but without vascular revision. One graft with hyperacute rejection was explanted 4 days postimplantation and one graft with primary nonfunction remained well perfused. Two patients died within 90 days, both with functioning grafts. Twenty-three grafts were re-explored within 7 days, including 9 solely for graft hypoperfusion. There were no postoperative arterial thromboses and, at re-exploration, no arterial anastomoses required revision. There were no postoperative venous thromboses, although one venous anastomosis was revised. No grafts were lost within 90 days for surgical or technical reasons compared with 76 (1.0%) of 7603 contemporaneous grafts in the ANZDATA Registry (P=.077 Fisher's exact test, P=.069 χ2 test). The routine use of intraoperative ultrasound appears to be of benefit by identifying otherwise unrecognized vascular abnormalities, leading to a reduction in early graft losses because of surgical factors.

Three-dimensional pseudo-continuous arterial spin labeling for evaluation of cerebral hemodynamic changes after revascularization in adult patients with moyamoya disease

To evaluate cerebral hemodynamic changes using three-dimensional pseudo-continuous arterial spin labeling (3D-pCASL) and its association with the changes of neurological symptoms in adult patients with moyamoya disease after revascularization. We prospectively collected the clinical and radiographic data of 40 adult patients with moyamoya disease diagnosed by digital subtraction angiography (DSA) or magnetic resonance angiography (MRA) undergoing unilateral superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis. All the patients underwent 3D-pCASL examination before and after the surgery, and were followed up for 3 to 11 months after the operation. The region of interest (ROI) was located in the middle cerebral artery cortical territory covering the surgical side and ipsilateral cerebellar hemisphere. Cerebral blood flow (CBF) and relative CBF (rCBF) values were compared before and after the surgery, and the changes in cerebral hemodynamics were evaluated. The correlations were analyzed between preoperative rCBF and Suzuki stage and between the changes in postoperative neurological symptoms and rCBF. The mean CBF of the patients increased significantly from 53.96±10.04 mL·100 g-1·min-1 to 58.90±13.57 mL·100 g-1·min-1 after the operation (t=-3.068, P=0.004); the mean rCBF also increased significantly after the operation (0.96 ± 0.14 vs 1.15 ± 0.18; t=-7.155, P < 0.001). The changes in postoperative neurological symptoms were significantly correlated with the changes in rCBF (P=0.017) and the type of disease onset (P < 0.001). 3D-pCASL is an valuable means for noninvasive monitoring of hemodynamic changes after revascularization in adult patients with moyamoya disease without the use of contrast agent.

Acute hypoxemia due to right-to-left shunt via a patent foramen ovale during left internal thoracic artery to left anterior descending artery anastomosis in off-pump coronary artery bypass grafting: a case report

BackgroundA right-to-left shunt via a patent foramen ovale (PFO) during off-pump coronary artery bypass (OPCAB) may result in difficulties in oxygenation and circulatory management. We herein present a case of a marked shunt via a PFO during OPCAB.Case presentationA 74-year-old man who had aortic root enlargement, compressing the right atrium, and an atrial septal aneurysm, underwent OPCAB. When the heart was fixed for the anastomosis of the left anterior descending artery, sudden hypoxemia and hypotension were observed. Intraoperative transesophageal echocardiography (TEE) showed a right-to-left shunt via a PFO that was unnoticed preoperatively. After the anastomosis was completed, TEE revealed no shunt through the PFO.ConclusionsWe should check for a PFO in case of an atrial septal aneurysm. Compression of the right atrium is considered an important anatomical risk of the right-to-left shunt in OPCAB.

Morphology of the brain base arteries of the giant anteater (Myrmecophaga tridactyla)

This study aimed to describe the brain base arteries of the Myrmecophaga tridactyla using ten cadavers of adults from this species, including five male and five female specimens. The arterial vascular bed was perfused via the thoracic aorta with a dyed natural latex solution, and the animals were fixed and preserved with a 10% formaldehyde buffered solution. The encephala were removed, and their vessels dissected. Basilar artery formation occurred by anastomosis of the thick ventral spinal artery with vertebral arteries. The basilar artery formed two arterial islands and gave bulbar and pontine branches, and cranial, middle, and caudal cerebellar arteries and ended by forking into its terminal branches, the caudal communicating arteries. The blood supply of the encephalon derived solely from the vertebrobasilar system, and the arterial circle of the brain was closed caudally and rostrally. The absence of participation of internal carotid arteries in encephalon irrigation, the island formations by the basilar artery, and the fusiform shape of the arterial circle of the brain are peculiar characteristics of the vascular anatomy of the brain base of M. tridactyla.

Abstract P2-15-02: Omentum-Lipoaspirate Free-Flap Breast Reconstruction in Women with BMI &amp;lt;25

Abstract The Omental Fat-Augmented Free-flap (O-FAFF) is being offered at our institution as an alternative method of breast reconstruction. This novel free-flap construct is ideal for underweight and normal weight women who lack abdominal or other donor tissue, desire to avoid donor site morbidity and/or are averse to implant-based reconstruction. We analyze omentum, mastectomy and final construct weights in women with BMI &amp;lt; 25 kg/m2 who underwent nipple-sparing mastectomies and O-FAFF reconstruction. Methods Operative technical features of women undergoing nipple-sparing mastectomies with immediate O-FAFF breast reconstruction over a 34 month period are included. Steps of the operative procedure are as follows: laparascopic omentectomy, liposuction and unilateral or bilateral mastectomy is performed. An acellular dermal matrix (ADM) shell is fashioned around a tissue expander. This mold is filled with the omentum and then engrafted with lipoaspirate followed by microsurgical anastomoses of gastroepiploic artery and vein to internal mammary artery and vein. Weight of biological construct is compared to native breast weight. Results 26 women with average BMI 21.2 kg/m2 underwent unilateral (15) or bilateral (11) nipple-sparing mastectomies and O-FAFF reconstruction. Average omentum weight for 37 breasts was 149 gm (82- 262) and average mastectomy weighed 212.4 gm (85 – 396). The ratio of engrafted fat to omentum weight was 0.73 for unilateral versus 0.91 for bilateral cases. The ratio of omentum-fat graft construct to mastectomy weight was 1.24 for unilateral and 0.96 for bilateral cases. Conclusion O-FAFF is a novel procedure for autologous tissue breast reconstruction after nipple-sparing mastectomy in underweight and normal weight women. Comparable weight replacement for extirpated native breast is achieved. Citation Format: Irene L. Wapnir, Monica M. Dua, Yulia Zak, Dung Nguyen. Omentum-Lipoaspirate Free-Flap Breast Reconstruction in Women with BMI &amp;lt;25 [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-15-02.

Abstract Number ‐ 56: Investigation of Aneurysmal Initiation Factor with Experimental Animal Model by Computational Fluid Dynamics Analysis

Introduction Hemodynamics has been reported to be involved in the pathophysiology of the initiation of intracranial aneurysms. Computational fluid dynamics (CFD) simulation has been widely used to investigate what kind of hemodynamics is related to intracranial aneurysm development or rupture. However, in the case of humans, it is difficult to obtain cerebrovascular images before the aneurysm formation because most of them are detected incidentally by magnetic resonance angiography (MRA) or computed tomography angiography (CTA). Therefore, the mechanism of aneurysm initiation has not been elucidated yet. In this study, CFD analysis was conducted with experimental animal models. Furthermore, immunostainings and Elastica van Gieson (EvG) staining were also performed to investigate the relationship between hemodynamics and aneurysm initiation. Methods We selected the experimental aneurysm model of a rat proposed by Shimizu et al.[1] With this model, aneurysms can be induced with a certain probability at the artificial bifurcation site created by end‐to‐side anastomosis of bilateral common carotid arteries and induced hypertension. Among the 50 rats surgically manipulated, 5 de novo cases and 14 cases without aneurysm initiation defined as stable cases were included in this study. The other 31 cases were excluded because of death or lack of imaging quality. MRA was conducted weekly until 4 weeks after manipulation. Acquired images were processed for the CFD analysis and various kinds of hemodynamic parameters were calculated. Among them, we regarded dimensionless wall shear stress divergence (WSSD*) and pressure loss coefficient (PLc) as the hemodynamic parameters previously suggested to be related to aneurysm initiation[2]. Vessels were collected after 2 weeks of follow‐up, and we observed endothelial cells (EC), smooth muscle cells (SMC), and the internal elastic lamina (IEL) at the apex of the bifurcationby immunostaining and EvG staining. Results The CFD results showed that a high WSSD* area existed at the apex of bifurcation in both de novo cases and stable cases. The averaged WSSD* of the de novo cases was 18.2% higher than that of the stable cases (de novo: 0.577 ± 0.243, stable: 0.488 ± 0.235). Likewise, the average PLc of the de novo cases was 11.5% higher than that of the stable cases (de novo: 8.22 ± 1.76, stable: 7.37 ± 2.49). The immunostaining images demonstrated that EC and SMC were more degenerated in de novo cases than in stable cases. Furthermore, the EvG staining images showed that IEL degenerated only in the de novo cases. Therefore, because WSSD* and PLc indicate a stretching force and flow impingement on the vessel wall, respectively, the elevation of those parameters may contribute to damage of EC, SMC, and IEL known as pathological features of an intracranial aneurysm. Conclusions CFD analysis and tissue observation were conducted with the vessels of the experimental animal model (5 de novo cases and 14 stable cases). Our results indicate that high WSSD* and high PLc are the factors related to aneurysm initiation.

Abstract Number ‐ 120: Using Gadolinium‐based Contrast in Middle Meningeal Artery Embolization: A Case Series

Introduction Nonacute subdural hematoma (SDH) is a common pathology, particularly in the elderly population, affecting 74 persons per 100 000 aged &gt;65 years old. Though surgical evaluation is the current golden standard treatment for symptomatic NASDH, there has been a paradigm shift towards middle meningeal artery embolization (MMAe), which is less invasive and addresses the underlying pathophysiology. MMAe traditionally uses iodine‐based contrast angiography to assess the anatomy and other branches relative to the distribution of the SDH. Due to the abrupt shortage of intravenous iodine‐based contrast secondary to COVID19 pandemic and consequent April 1,2022 lockdown in Shanghai manufacturers (GE Healthcare), we report three successful cases of MMAe utilizing gadolinium‐based contrast angiography. Methods Informed consent that an alternative contrast medium was obtained from the patients. All procedures were done under general anesthesia, see methods below. All patients tolerated the procedures well, without any nausea, urticaria, angioedema, or bronchospasm. On 6–8 weeks outpatient follow‐up and repeat imaging, all patients have near resolution or improvement of SDH size and no lasting post‐procedural complications were reported. Results Case 1: A 50‐year‐old man with history of traumatic SDH (5 months prior) presented with 5 days history of dysarthria and lethargy. Computed tomography head (CTH) revealed non‐acute bilateral subdural hemorrhage with 6 mm left‐to‐right midline shift. Patient then underwent burr hole evacuation of left‐sided subdural hematoma, and subsequently underwent prophylactic left MMAe and upfront right MMAe. With a transradial approach, 41 cc of gadoteridol contrast (ProHANCE) was used for angiography. No significant ophthalmic artery anastomosis was observed. PVA particles measuring 150–250 microns were then injected until there was significant stasis of forward flow and reflux around the catheter tip. Case 2: A 49‐year‐old man with history of traumatic SDH (6 months prior) presented with 1 month history of headaches, word‐difficulty finding and right sided clumsiness. CTH revealed 2.3 cm mixed density left SDH with a 1.6 mm left‐to‐right midline shift. Patient underwent left frontotemporoparietal craniotomy and subdural hematoma evacuation. 3 days later, patient underwent prophylactic left MMAe using a transfemoral approach with 6.1 cc of gadoterate meglumine (Dotarem) contrast for angiography. No definite external‐to‐internal dangerous collateral pathways were noted and no ocular supply was seen. Liquid embolization proceeded utilizing Onyx 34 with penetration into mid‐level meningeal branches. Case 3: A 55‐year‐old woman presented with 2‐week history of headaches and blurry vision. CTH showed a large 2.2 cm left mixed density SDH with 9.6 mm left‐to‐right midline shift. Patient underwent burr hole evacuation of left‐sided subdural hematoma and subsequent left prophylactic MMAe. With a transfemoral approach, 6.7 cc of gadoteridol contrast (ProHANCE) was used for angiography. No obvious external to internal dangerous collateral pathways were noted. The balloon catheter was advanced just proximal to the bifurcation and liquid embolization with Onyx 34 was achieved. The middle meningeal artery demonstrated complete occlusion proximal to the bifurcation. Conclusions This case series suggests that utilizing a gadolinium‐based contrast for angiography to guide MMA embolization is feasible, effective in visualization of dangerous external‐to‐internal anastomoses (including the ophthalmic artery), and safe for patients.

Complete Bony Segment Flap Failure without Skin Paddle Compromise in Fibular Free Flap: A Case Report of a Rare Early Complication

The free fibula flap is sometimes associated with partial flap loss. A 62-year-old man with squamous carcinoma of the lower alveolus underwent anterior arch resection and reconstruction with a fibula osteocutaneous flap containing three bony segments. There were two perforators in the skin flap; the first perforator was proximal to the bony segments and the other perforator was at the level of the middle segment. Atherosclerosis was observed in the anastomotic vessels. During surgery, thrombosis occurred in the arterial anastomosis, but was revised before the operation was over. The patient’s early postoperative course was uneventful. In the second week, purulent discharge was observed from the drains. Flap exploration showed devascularization of bony segments and periosteum, but the skin paddle was viable. The peroneal vessel had thrombosed distal to the takeoff of the proximal perforator and the viable skin paddle perfused by proximal perforators falsely indicated the well-being of underlying bones. The de-vascularized bones and sloughed periosteum were removed at the time of exploration, after which the skin paddle was reoriented for coverage of the defect. The patient completed chemoradiation without any bony reconstruction afterwards. This is the only reported case of early total bony flap portion loss with a viable skin paddle in free fibula flap transfer.

Is Prolonged Use of Antibiotic Prophylaxis and Postoperative Antithrombotic and Antispasmodic Treatments Necessary After Digit Replantation or Revascularization?

Is Prolonged Use of Antibiotic Prophylaxis and Postoperative Antithrombotic and Antispasmodic Treatments Necessary After Digit Replantation or Revascularization?

Development of Neovasculature in Axially Vascularized Calcium Phosphate Cement Scaffolds

Augmenting the vascular supply to generate new tissues, a crucial aspect in regenerative medicine, has been challenging. Recently, our group showed that calcium phosphate can induce the formation of a functional neo-angiosome without the need for microsurgical arterial anastomosis. This was a preclinical proof of concept for biomaterial-induced luminal sprouting of large-diameter vessels. In this study, we investigated if sprouting was a general response to surgical injury or placement of an inorganic construct around the vessel. Cylindrical biocement scaffolds of differing chemistries were placed around the femoral vein. A contrast agent was used to visualize vessel ingrowth into the scaffolds. Cell populations in the scaffold were mapped using immunohistochemistry. Calcium phosphate scaffolds induced 2.7-3 times greater volume of blood vessels than calcium sulphate or magnesium phosphate scaffolds. Macrophage and vSMC populations were identified that changed spatially and temporally within the scaffold during implantation. NLRP3 inflammasome activation peaked at weeks 2 and 4 and then declined; however, IL-1β expression was sustained over the course of the experiment. IL-8, a promoter of angiogenesis, was also detected, and together, these responses suggest a role of sterile inflammation. Unexpectedly, the effect was distinct from an injury response as a result of surgical placement and also was not simply a foreign body reaction as a result of placing a rigid bioceramic next to a vein, since, while the materials tested had similar microstructures, only the calcium phosphates tested elicited an angiogenic response. This finding then reveals a potential path towards a new strategy for creating better pro-regenerative biomaterials.

Ruptured aneurysms at the distal superior cerebellar artery successfully treated by combining occipital artery-superior cerebellar artery anastomosis and endovascular therapy: illustrative case.

Distal superior cerebellar artery (SCA) aneurysms are rare and are treated using various treatment strategies. Treatment often requires parent artery occlusion, which raises concerns regarding the potential risk of ischemia in the distal territory. An 81-year-old woman presented with subarachnoid hemorrhage. Diagnostic cerebral angiography revealed two tiny distal SCA aneurysms. Because significant ischemic damage following parent artery occlusion was concerned, two bypasses between the occipital artery and SCA branches were first performed with the patient in the prone position in a hybrid operating room. Each aneurysm was successively treated in the same position with endovascular internal trapping and intra-aneurysmal embolization. After adequate hemostasis was confirmed, the wound was closed. Both aneurysms were successfully occluded without symptomatic ischemic complications. This combined surgical and endovascular approach would be helpful in cases with notable concerns regarding ischemia after sacrificing the parent artery.

Once in a Blue Moon: Iatrogenic Coronary Dissection in Anomalous Coronary Artery

Coronary anomalies present as a rare phenomenon. One of the most observed coronary anomalies is the single coronary artery (SCA) originating from one coronary ostium and dividing into the coronary arteries in various configurations1Angelini P. Coronary artery anomalies: an entity in search of an identity.Circulation. 2007; 115: 1296-1305Crossref PubMed Scopus (532) Google Scholar, classified by Lipton’s Classification.2Lipton M.J. Barry W.H. Obrez I. Silverman J.F. Wexler L. Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance.Radiology. 1979; 130: 39-47Crossref PubMed Scopus (414) Google Scholar A 38-year-old male patient was admitted to a community hospital with typical signs of non-ST-elevation myocardial infarction (NSTEMI) but without any known comorbidities. Urgent coronary angiography revealed a rare anomaly (incidence of 0.008%3Yamanaka O. Hobbs R.E. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography.Cathet Cardiovasc Diagn. 1990; 21: 28-40Crossref PubMed Google Scholar,4Mohanty A. Chandra S. A rare case of 'superdominant' single coronary artery.Indian Heart J. 2015; 67: 389-391Abstract Full Text Full Text PDF Google Scholar) of an SCA with the left coronary system originating from the right coronary periphery, posterior to the great vessels (Lipton’s Classification R-IP, table 1) and occlusion of the circumflex artery (CX) (figure 1a-b, video 1). A culprit-lesion percutaneous coronary intervention was attempted. However, despite the use of various flexible guidewires and angled microcatheters (90°) CX passage through the left main artery equivalent (LMA) was not achieved (video 2) and resulted in ST elevation. A prompt control demonstrated a dissection of the LMA (figure 1c, video 3). Further interventional approaches were waived and the patient was transferred for surgical revascularization.Table 1Lipton’s Single Coronary Artery Classification2Lipton M.J. Barry W.H. Obrez I. Silverman J.F. Wexler L. Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance.Radiology. 1979; 130: 39-47Crossref PubMed Scopus (414) Google ScholarCodeDescriptionOstial LocationRRight Sinus of ValsalvaLLeft Sinus of ValsalvaAnatomical DistributionIThe solitary domain vessel follows the course of either a normal right or left coronary arteryIIOne coronary artery arises from the proximal part of the normally located other coronary arteryIIILAD and CX arise separately from a common trunk originating from the right sinus of ValsalvaCourse of the Transverse TrunkAAnterior to the great vesselsBBetween the aorta and the pulmonary arteriesPPosterior to the great vesselsSSeptal Type: A part of the route passes through the interventricular septumCCombined Type: Combination of diverse routes Open table in a new tab Intraoperatively, coronary dissection could be confirmed, whereas the left anterior descending artery (LAD) and CX were identified in the typical locations. Coronary revascularization was performed by anastomosis of the left internal mammary artery to the LAD, and a saphenous vein graft to the CX in perfusion-assisted beating heart technique. The postoperative course remained uneventful and the patient was discharged on the 10th postoperative day. The main issue in SCA persists in the dependency on one system with fatal results in proximal occlusion. Since the overall incidence of coronary anomalies is very low3Yamanaka O. Hobbs R.E. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography.Cathet Cardiovasc Diagn. 1990; 21: 28-40Crossref PubMed Google Scholar, the treatment strategy for acute coronary syndromes in patients with anomalous coronary anatomy remains questionable. In particular, an interventional approach in complex coronary anatomy can result in coronary injury. Since in cases of myocardial infarction time matters most, a deep – even inter-hospital – heart team approach is crucial to maintain in-time life-saving treatments. •Lipton’s Classification R-IP is the rarest form of single coronary artery configuration with the left coronary system originating from the right coronary periphery.•Percutaneous coronary intervention of the left coronary system may be very challenging in Lipton’s Classification R-IP•Surgical revascularization is a reasonable strategy in particular when the coronary periphery location is in typical location.•A deep heart team approach is crucial to maintain in-time life-saving treatments in such critical and complex cases. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI1ZWIwZTk5NTRiZWEzMDA2MGVlNzI5MmM4OTZjNDlmYyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc2MjA3NTg4fQ.My1bJvayG27S7R8PKVtQsWVd9XLKhwldpsEWqzuMHIzYxOz_VIFRiJulyjzbngC4CyNUqZMU_qmU-_r_3QPgVbNU2xkwNmcDVsxgXDGD3oSMx3rmyXQK-bNXjlY-qh_YzCrTQ4UEB8jH1qiVcNVpHyrGc-MtRjc7v89p3xEBD1aa_Ns-xk1OOfXUrdGlF9O7EQX7iWrHtaVkLbdCUhgxc55eQP4YI97gKqxSTzFKe4nOdxPc5K41oBsMkajdNYt83O5oDph59QzDCmbWJJDlinjzvGQqRFcavZjX7emVYeuqr5DOGxgmXTA36j331owW-wzHpdKn7wy_SAu2l1u30g Download .mp4 (3.49 MB) Help with .mp4 files eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIzYjhkMDgxYzg2OTRiYTM0MDZmYTgyZDcyYzcxMmI1NyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc2MjA3NTg4fQ.gH37xsv4GXLcsKMdb-SAuac7Xh_CpCm5C0UOpTzC6x5WB68zYxcjtSgpUhdMHve6TUbPHbeu4gyaKxxZOZFAyXhaMk3R4CzuIFQGSdNyQ3UbqN2MXekQOyGM0i6FNEiLMnWIlxCoQlwOvXWyQ1sI5cKCz5qIkr0f6r_5o2C3gv15nrn3mBIX3vPynprGA_1gHGfLtCQXAvMvVUwYfg-Ba-GOjt1NTSJ0ccCjlQefWR_6jSDTk7NX3BfZ5jU-ybtSzeAxEfALNpfSP2YHm960AaPVaXDNtI0CYb5bkGWLepuD3vzkGAahQrf2K23VUEfho5FELp_CpUVjx4EUMLZ3gA Download .mp4 (1.48 MB) Help with .mp4 files eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI2MTc2OTE5MTY2ZDM1OTQ1NTUzYTQ3MzcwOTc1OWJlNiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc2MjA3NTg4fQ.G5pvhhPUt-Kl_kxjdKfL-lOu-rH4hRhKzFlVwwANSrmNUjBoRc_thtwNvFupLmPpm1meakrWBTvBZ-JrBLOAlq6fW3AXl46Qy5drW5RxsehHs52zYd8GMPUQ9Trimxz6LG5NH50cVzlCWKi_iaZKUGpRueErVe1WFrp0YqXxkauvv-qmuoIW2pTQS1IpP-6E3u_z8OpKdj53TlaNfpGQJq3z28Uqw5FsY44sS9OP0k_A6uhflBqSRFLKU22pDTS3TPOUSqoxJAATd7yxU-H9QckIiu6lEHsAS2AKowXlAZiXHJnAcRaOBWAFkXx7eJ-MkLy7Eqms1glQNP6hxmoK4Q Download .mp4 (0.95 MB) Help with .mp4 files

The Impact of Hepatic Artery Thrombosis on the Outcome of Pediatric Living Donor Liver Transplantations

The aim of our study was to assess risk factors for hepatic artery thrombosis (HAT) and to evaluate the impact of HAT management on long-term outcomes after pediatric living donor liver transplantation (LDLT). We retrospectively analyzed 400 patients who underwent primary LDLT between 1999 and 2020. We compared preoperative data, surgical factors, complications, and patient and graft survivals in patients with HAT (HAT Group) and without HAT (non-HAT Group). A total of 27 patients (6.75%) developed HAT. Acute liver failure, a hepatic artery (HA) anastomosis diameter below 2 mm, and intraoperative HA flow dysfunction were significantly more common in the HAT Group (p < 0.05, p = 0.02026, and p = 0.0019, respectively). In the HAT Group, 21 patients (77.8%) underwent urgent surgical revision. The incidence of biliary stenosis and retransplantation was significantly higher in the HAT Group (p = 0.00002 and p < 0.0001, respectively). Patient and graft survivals were significantly worse in the HAT Group (p < 0.05). The close monitoring of HA flow with Doppler ultrasound during the critical period of 2 to 3 weeks after LDLT and the immediate attempt of surgical revascularization may attenuate the elevated risk of biliary stenosis, graft loss, and the need for retransplantation due to HAT.

Anastomotic complications after lung transplantation

: Anastomotic complications following lung transplantation include those affecting one of the three anastomoses performed in the usual technique for lung transplantation: the bronchial, the pulmonary artery, and the pulmonary venous anastomoses. Airway complications have declined over time, but still are associated with significant morbidity and mortality. The main pathogenic factor associated to the development of airway complications is the post-transplant bronchial ischemia. The most frequent anastomotic airway complication is bronchial stenosis. Other complications include bronchial dehiscence, granulation tissue formation, bronchomalacia, and bronchial fistulae. The main diagnostic tools for diagnosis of such complications are imaging techniques such as chest computed tomography (CT) scan and bronchoscopic examination, which allows an appropriate assessment of the bronchial mucosa and extent of the airway complication. A combination of several bronchoscopic procedures is usually required to best manage post-transplant airway complications. These include balloon dilatation, cryotherapy, laser resection, electrocautery, endobronchial brachytherapy, and bronchial stenting. On occasion, different surgical approaches are required, including graft resection or re-transplantation. The incidence of vascular anastomotic complications after lung transplantation is low, but they are associated to high morbidity and mortality rates. These complications comprise either the pulmonary artery anastomosis or the venous anastomosis, and stenoses are the most frequently observed. In the pulmonary artery, an excessive length of vascular ends may lead to kinking, vascular torsion, and stenosis. In the venous anastomosis, an improper surgical technique, or an anastomotic intussusception due to excessive lengh leads to the development of thrombosis at the anastomotic site. Early detection and rapid treatment of these complications is crucial for its successful management. Appropriate selection of the best therapeutic option depends on the time of onset of the vascular complication and the expertise of the transplant team. It usually requires a multidisciplinary approach comprising either endovascular procedures or surgical correction.

A Comparison of Outcomes between Finger and Pulp Replantation/Revascularization in a Single Center.

In a retrospective case study over a 5-year period at our institute, a total of 21 patients (n = 21) had either finger or pulp replantation-revascularization posttrauma. All pulp replants had a single-vessel anastomosis viz., "artery-to-artery" or "artery-to-vein" only, with venous outflow dependent on the skin-shave technique, while more proximal replants had both arterial and venous anastomoses. Age, sex, ischemic time, handedness, smoker status, and injury-replant interval were compared between the two groups, with all procedures performed by a single surgeon. The outcome parameters studied were length of hospital stay, timeline for wound healing, viability, and functional outcomes. Our patients consisted of 18 men and three women, of which 14.3% were smokers and 85.7% were right-handed. There were 11 finger replantation/revascularizations (n = 11) versus 10 pulp replantation/revascularizations (n = 10). The average age of digit replantation/revascularization patients was 44.8 years compared with 26.4 years in pulp replantation/revascularization patients (Student t test, P = 0.04). Mean ischemia time in digital replants was 67 minutes versus 32.3 minutes in pulp replantation/revascularization (Student t test, P = 0.056). Digital replantation/revascularization was viable in 72% of cases versus a 90% viability in the pulp subcohort. In our patient cohort, pulp replantation/revascularizations produced better postoperative viability. Where supermicrosurgery expertise is available, pulp replantation/revascularization should be considered a worthwhile option when compared with digital replantation/revascularization.