Arterial Reconstructive Surgery Research Articles

Executive Summary: Fostering Collaborative Teamwork-A Comprehensive Approach to Vascular Graft Infection Following Arterial Reconstructive Surgery.

Vascular graft infection (VGI) is one of the most serious complications following arterial reconstructive surgery. VGI has received increasing attention over the past decade, but many questions remain regarding its diagnosis and management. In this review, we describe our approach to VGI through multidisciplinary collaboration and discuss decision-making for challenging presentations. This document will concentrate on VGI that impacts both aneurysms and pseudoaneurysms excluding the ascending thoracic aorta.

Fostering Collaborative Teamwork-A Comprehensive Approach to Vascular Graft Infection Following Arterial Reconstructive Surgery.

Vascular graft infection (VGI) is one of the most serious complications following arterial reconstructive surgery. VGI has received increasing attention over the past decade, but many questions remain regarding its diagnosis and management. In this review, we describe our approach to VGI through multidisciplinary collaboration and discuss decision making for challenging presentations. This review will concentrate on VGI that impacts both aneurysms and pseudoaneurysms excluding the ascending thoracic aorta.

Claudication due to adventitial cystic degeneration: A differential diagnosis of peripheral artery disease.

Cystic adventitial disease (CAD) is an important and rare non-atherosclerotic cause of intermittent claudication and critical limb ischemia. Since the first case of CAD involving the external iliac artery was described by Atkins and Key in 1947, approximately 300 additional cases have been reported. The aim of this article is to report a rare vascular disorder, predominantly seen in young healthy men with minimal cardiovascular risk factors. We report a rare case of cystic adventitial disease of a young policeman. To confirm the diagnosis, an ultrasonography and a conventional angiography were performed. The therapeutic approach was surgical first. The procedure was successful without any complication, and the patient was discharged to home 4 days after procedure. While CAD is rare, the diagnosis should be suspected in a young patient who presents with arterial insufficiency and no risk factors for atherosclerosis. Catheter angiography is the investigation of choice in the absence of multislice CT and good MRA. It seems that the treatment that assures the best long-term results is reconstructive arterial bypass surgery.

Extracellular signal-regulated kinase inhibition prevents venous adaptive remodeling via regulation of Eph-B4.

Vein graft adaptation (VGA) is a process that vein as a vascular graft conduits in arterial reconstructive surgery; VGA can lead to postoperative vein graft stenosis (VGS) and complications after coronary artery bypass graft and other peripheral artery bypass surgeries. VGA is characterized by vein graft loss the venous features without exhibiting arterial features; furthermore, the activation of ERK inhibited the maintenance of venous properties of the vein graft. We hypothesized that ERK inhibition can affect vein VGS through regulating the expression of EphB4. Rat vein transplantation model was established using wild-type and EphB4+/- Sprague-Dawley rats. Hematoxylin-eosin, Masson, Verhoeff, actin staining, and immunohistochemistry were applied to observe the structure of the vein grafts. Vascular smooth muscle cells (VSMCs) were isolated from the vein and vein grafts. Western blotting was used to determine the expression of p-ERK1/2 and EphB4, and immunofluorescence was applied to detect the expression and location of EphB4. Cell wound scratch assay and CCK8 assay were used to determine the migration and proliferation of VSMCs. Real-time polymerase chain reaction was used to determine the mRNA expression of EphB4. Western blotting in vein sample and vein graft sample detected p-ERK1/2 and ERK1/2 expression in both EphB4+/+ and EphB4+/- rats. The expression of p-ERK was increased in vein graft compared to vein. Immunofluorescence in VSMCs form EphB4+/+ and EphB4+/- rats detected EphB4 expression in both cells, and the expression of EphB4 was increased in VSMCs form EphB4+/+ rats. SCH772984 reduces the proliferation and migration of VSMCs. Inhibition of ERK suppressed the increase of vein graft wall thickness, and the expression of collagen fibers, elastic fibers, and α-actin was decreased. Vein graft from EphB4+/- rats reduces the expression of EphB4, and SCH772984 suppressed the decrease of EphB4 in vivo. Vein graft from EphB4+/- rats increased the expression of EphB4, and SCH772984 suppressed the increase of EphB4 in vivo. The inhibition of ERK1/2 suppressed the process of VGS by decreasing the proliferation of VSMCs. The ERK-inhibitor SCH772984 suppressed the level of VGS by extending the time of EphB4 expression during the process of VGA, thus maintaining the venousization of vein graft. The mechanism may be that the inhibitor SCH772984 suppresses the level of VGS by extending the time of EphB4 expression during the process of VGA. Therefore, our research provides a new target of VGS treatment by inhibiting the expression of ERK1/2 through the process of VGA.

Ex Situ Arterial Reconstruction During Normothermic Perfusion of the Liver.

Background.Aberrant hepatic arterial anatomy may be seen in up to 30% of liver grafts, and reconstruction prolongs the cold ischemic time or the arterialization times. If normothermic machine preservation (NMP) is used to preserve liver grafts, the presence of aberrant arterial anatomy poses a challenge. Dual arterial cannulation is a temporary solution to enable effective perfusion, until optimal circumstances are met for arterial reconstruction, without compromising ischemia time. To date the technical and logistical feasibility of arterial reconstruction ex situ and during NMP has not been reported.Methods.Series of 5 cases from the Consortium for Organ Preservation in Europe randomized controlled trial in which grafts with arterial anatomic variations were reconstructed while organs were perfused on NMP.Results.One donor after cardiac death and 4 donor after brain death livers with arterial anatomical variations reconstructed while on NMP were included. All patients survived transplantation, spending 1–7 d in intensive care unit and discharged home after 5–15 d. None of the cases developed early allograft dysfunction or any early technical complications. At follow-up, there were no late hepatic artery thrombosis, stenosis, or any other vascular–related complication. Four of 5 patients underwent magnetic resonance cholangiopancreatography at 6 mo with no evidence of ischemic cholangiopathy.Conclusions.The case series described above suggests that ex vivo arterial reconstruction surgery on liver grafts while on board the NMP device is feasible, safe, and effective.

Comparison of cytotoxicity of vascular prostheses in vitro

Aim. To study and compare cytotoxicity of the main types of synthetic prostheses used in arterial reconstructive surgery, including polytetrafluoroethylene (PTFE) and polyethylene-terephthalate (Dacron).
 Materials and Methods. On the culture of human umbilical vein endothelial cells (HUVEC) of the 3rd passage, MTS test was conducted that is used in laboratory examinations with attraction of cellular technologies to study cytotoxicity of medical drugs and medical products. The test implies use of MTS reagent that is 3-(4,5-dimethylthiazol-2-il)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium; additionally phenazine methosulfate (PMS) was used that plays the role of electron-binding reagent. In the experiment, cells were incubated with PTFE and Dacron within 24 hours at 37ᵒC with 5% CO2. For control, HUVEC cultured in the standard growth medium, were used. In the presence of PMS, MTS was reduced by mitochondrial dehydrogenases of endothelial cells to formazan staining blue. Supernatant of cell cultures was evaluated by photocolorimetric method on Stat Fax 3200 analyzer (microplate reader) of Awareness technology Inc. Palm City Fl. (USA).
 Results. The lowest mean values were noted in Dacron group 0.21 (0.20-0.22) optical density units, the highest values were noted in the control group 0.36 (0.35-0.38); parameters in PTFE group were 0.35 (0.33-0.36). In comparison of the groups statistically significant differences were found between the control group and Dacron group (р0.001), control and PTFE group (р=0.037), Dacron and PTFE (р0.001). Incubation with Dacron led to suppression of metabolic activity of cells by 41.7% as compared to the control group (р0.001). Metabolic activity of cells exposed to PTFE, approached that of the control group, that is, it corresponded to the optimal conditions of culturing of endothelial cells in vitro.
 Conclusion. In comparison with polyethylene-terephthalate (Dacron), polytetrafluoro-ethylene (PTFE) showed the least suppression of metabolic activity of endothelial cells in vitro.

Ruptured Popliteal Artery Aneurysm Complicated with Acute Respiratory Distress Syndrome Secondary to SARS-CoV-2 Infection

We herein report a rare case of the ruptured popliteal artery aneurysm in an 89-year-old man, whose recovery after surgical treatment was complicated with acute respiratory distress syndrome secondary to confirmed infection with SARS-CoV-2. Presenting symptoms, patient's comorbidities, and postoperative course complicated with cardiac and respiratory failure leading to adverse outcome are discussed in this case report.

Реперфузионно-реоксигенационный синдром как проблема реконструктивной хирургии артерий при хронической ишемии нижних конечностей атеросклеротического генеза

Реперфузионно-реоксигенационный синдром как проблема реконструктивной хирургии артерий при хронической ишемии нижних конечностей атеросклеротического генеза

Inflammation and myointimal hyperplasia. Correlation with hemodynamic forces

ObjectivesThe aim of our study was to correlate flow dynamics and the release of inflammatory cytokines Interleukin 1, 2, 6, TNF (Tumour Necrosis Factor) alfa, both in vitro and in vivo. Materials and methodsEndothelial cells were exposed to laminar flow (6dyne/cm2) in an in vitro circulatory system and the release of Interleukin 1, 2, 6 and TNF alfa was quantified by ELISA. Interleukin 1, 2, 6 and TNF alfa release was also assessed in vein grafts implanted in the arterial circulation of Lewis rats. Arterial vein grafts were explanted at different time intervals from 3days to 12weeks after surgery. Vein grafts implanted in the arterial circulation for 4weeks, were re implanted in the venous circulation of syngenic Lewis rats, and the release of Interleukin 1, 2, 6 and TNF alfa, was assessed in an organ culture.Six vein grafts (4 occluded, 2 patent) implanted in humans as femorodistal bypass were examined for the presence of myointimal hyperplasia and perigraft inflammatory cells. ResultsIn vitro, endothelial cells exposed to laminar flow released an increased amount of Interleukin 1, 2, 6 and TNF alfa in comparison to endothelial cells not exposed to flow.In experimental vein grafts implanted in the arterial circulation there was an increased release of inflammatory cytokines associated to inflammatory changes in the adventitia. Once the vein grafts were re implanted in the venous circulation, the release of these cytokines diminished, while the inflammatory changes in the adventitia regressed. ConclusionsIncreased shear stress induces release of cytokines and inflammatory changes in the adventitia. These inflammatory changes can contribute to plaque progression and to un stable plaque. These findings support the use of anti-inflammatory therapy in patients prone to develop atherosclerosis and in those who had arterial reconstructive surgery.

Murine Aortic Crush Injury: An Efficient In Vivo Model of Smooth Muscle Cell Proliferation and Endothelial Function.

Arterial reconstruction, whether angioplasty or bypass surgery, involves iatrogenic trauma causing endothelial disruption and vascular smooth muscle cell (VSMC) proliferation. Common murine models study small vessels such as the carotid and femoral arteries. Herein we describe an in vivo system in which both VSMC proliferation and endothelial barrier function can be simultaneously assessed in a large vessel. We studied the infrarenal aortic response to injury in C57BL/6 mice. The aorta was injured from the left renal vein to the aortic bifurcation by 30 transmural crushes of 5-seconds duration with a cotton-tipped applicator. Morphological changes were assessed with conventional histology. Aorta wall thickness was measured from the luminal surface to the adventitia. EdU integration and counter staining with DAPI and alpha-actin was used to demonstrate VSMC proliferation. Activation of ERK1/2, a known moderator of intimal hyperplasia formation, was determined by Western Blot analysis. The effect of inflammation was determined by immunohistochemistry for B-cells, T-cells, and macrophages. En face sections of endothelium were visualized with scanning electron microscopy (SEM). Endothelial barrier function was determined with Evans Blue staining. Transmural injury resulted in aortic wall thickening. This injury induced VSMC proliferation, most prominently at 3 days after injury, and early activation of ERK1/2 and decreased p27kip1 expression. Injury did not result in increased B-cells, T-cells, or macrophages infiltration in the vessel wall. Injury caused partial endothelial cell denudation and loss of cell-cell contact. Injury resulted in a significant loss of endothelial barrier function, which returned to baseline after seven days. The murine transmural blunt aortic injury model provides an efficient system to simultaneously study both VSMC proliferation and endothelial barrier function in a large vessel.

Patterns of Superficial Veins of the Middle Upper Extremity in Caucasian Population

Superficial veins of the middle upper extremity are frequently variable in existence and arrangement. The superficial veins are clinically important in many revascularization procedures, particularly reconstructive microsurgery and arterial bypass surgery as well as intravenous injection or therapy. The aim of this study was to assess the patterns of superficial veins of middle upper extremity in healthy volunteers. We examined both arms of 169 people. A tourniquet was applied at the mid-arm and a drawing made of the pattern of veins. It took about 1-3 min for each arm. We then examined the 338 drawings looking for similar patterns. The study took place in Department of Anatomy, Faculty of Medicine in Novi Sad, Serbia. We found nine patterns of middle upper extremity veins. The most common was an 'M'-shaped pattern (115/338, 34%) followed by an 'N'-shaped pattern (97/338, 29%). There are only nine basic patterns of middle upper extremity venous anatomy. Some are more common than others. This knowledge should help those needing venous access for medical procedures (venepuncture, transfusion, infusion, cardiac catheterization, placement of dialysis access).

Реперфузионное повреждение тканей в хирургии артерий нижних конечностей

Реперфузионное повреждение тканей в хирургии артерий нижних конечностей

Antibiotic Prophylaxis in Autologous Vein Graft Reconstructions of the Lower Extremity.

Different factors contribute to infection after arterial reconstructive surgery. Prophylactic antibiotic use during surgery is widespread, however, there is insufficient evidence to support the use of prophylactic antibiotics with autologous vein grafting. The aim of our study was to assess the effect of single-dose prophylactic antibiotics in patients undergoing autologous vein grafting. Patients undergoing arterial bypass reconstruction in the lower extremity between 2004 and 2012 were retrospectively screened for use of vein grafts. Patients receiving single-dose antibiotic prophylaxis (group 1) were compared with those not receiving prophylaxis (group 2). Primary outcome was surgical site infection (SSI), and 142 patients were included. The SSI occurred in 22% of patients in group 1 and in 29% of patients in group 2 (P = .39; odds ratio: 1.46 confidence interval 95%: 0.61-3.47). Results showed no significant effect from single-dose antibiotic prophylaxis on lowering the incidence of SSI.

Periodontal disease and late-onset aortic prosthetic vascular graft infection.

Prosthetic vascular graft infection (PVGI) is a rare but significant complication of arterial reconstructive surgery. Although the relative risk is low, the clinical consequences can be catastrophic. Microbiological data on causative bacteria are limited. We present four cases of late-onset PVGI. Using a culture-independent nucleic acid amplification method for analysis of intraoperative samples, the presence of bacteria highly suggestive of an oral source was reported. Examination by an oral health specialist confirmed the presence of chronic periodontal disease. We hypothesize that chronic oral infection may be a previously unreported risk factor for the development of late-onset PVGI.

The in vivo blood compatibility of bio-inspired small diameter vascular graft: effect of submicron longitudinally aligned topography

BackgroundCardiovascular disease is the leading cause of deaths worldwide and the arterial reconstructive surgery remains the treatment of choice. Although large diameter vascular grafts have been widely used in clinical practices, there is an urgent need to develop a small diameter vascular graft with enhanced blood compatibility. Herein, we fabricated a small diameter vascular graft with submicron longitudinally aligned topography, which mimicked the tunica intima of the native arterial vessels and were tested in Sprague–Dawley (SD) rats.MethodsVascular grafts with aligned and smooth topography were prepared by electrospinning and were connected to the abdominal aorta of the SD rats to evaluate their blood compatibility. Graft patency and platelet adhesion were evaluated by color Doppler ultrasound and immunofluorescence respectively.ResultsWe observed a significant higher patency rate (p = 0.021) and less thrombus formation in vascular graft with aligned topography than vascular graft with smooth topography. However, no significant difference between the adhesion rates on both vascular grafts (smooth/aligned: 0.35‰/0.12‰, p > 0.05) was observed. Moreover, both vascular grafts had few adherent activated platelets on the luminal surface.ConclusionBionic vascular graft showed enhanced blood compatibility due to the effect of surface topography. Therefore, it has considerable potential for using in clinical application.

Low Hemoglobin Concentration Is Associated With Poor Outcome After Peripheral Arterial Surgery

To assess the influence of low hemoglobin (Hb) concentration on major adverse cardiac events (MACE) and mortality in patients undergoing peripheral arterial surgery. This was a retrospective cohort study of patients undergoing peripheral arterial reconstructive surgery at a tertiary vascular center. Preoperative factors linked with the occurrence of MACE and death on univariate analysis (P ≤ .1) were included in a multivariate model to confirm the independent association with the outcome variables. A total of 360 consecutive patients (238 men) with a mean (standard deviation) age of 69 (10.7) years and Hb of 13.0 (2.12) g/dL treated under the care of a single specialist between January 2004 and December 2011 were included in the analysis. Of these, 193 (53.6%) were anemic. In all, 26 (7%) had a postoperative MACE and 18 (5%) died. On multivariate analysis, age > 80 years (odds ratio [OR] = 3; 95% confidence interval [CI] [1.2-7.5]; P = .025), renal impairment (OR = 3.2; 95% CI [.99-10.2]; P = .053), coronary disease (OR = 3.6; 95% CI [1.5-8.7]; P = .005), and low Hb (OR for each 1 g/dL drop below the mean = 1.4 [1.13-1.7]; P = .002) were independent risk factors for MACE. Unplanned surgery (OR = 4.5; 95% CI [1.2-16.9]; P = .025) and low Hb (OR for each 1 g/dL drop below the mean = 1.5; 95% CI [1.14-1.86]; P = .002) were independent risk factors for death. In peripheral arterial surgery, preoperative low Hb is associated with MACE and death. Further investigation is necessary to elucidate whether this relationship is causal. Meanwhile, consideration should be given to treating preoperative anemia as a significant risk factor for adverse outcome in this setting.

Instant and long-term results of surgical treatment in patients with peripheral vascular disease as a complication of diabetes mellitus

Aim. To define the indications and to evaluate the effectiveness of various surgical treatment methods in patients with arterial stenosis and occlusion due to atherosclerotic vascular disease of lower extremities as a complication of diabetes mellitus. Methods. Results of surgical treatment of 52 randomly assigned patients who underwent surgeries due to peripheral vascular disease as a complication of diabetes mellitus (type 2 - 51 patients, type 1 - 1 patient) were analyzed. The following surgeries were performed: arterial reconstructive surgery - 24 (46.2%) patients (group 1), balloon catheter angioplasty and stenting - 12 (23.1%) patients (group 2), indirect revascularization surgery (revascularising osteotrepanation, endovascular prostaglandin E therapy) - 16 (30.7%) patients (group 3). Following parameters were assessed: decrease of ischemic rest pain, arterial insufficiency stage, hospitalization terms, healing of foot ulcers, mortality rate, and amputation rate. The longest foot ulcers healing terms [only in 5 patients (31.2%) at first year] were registered in the third group. 1 death was registered each in the first and in second groups (mortality rate 4.2 and 8.3% respectively), no deaths were registered in group 3. The results of trophic ulcers treatment in the patients from the third group were poor. It is tactically appropriate to prefer endovascular surgeries to open surgeries as far as in this case there is no need for local and general anesthesia allowing to decrease the number of complications and the length of rehabilitation together with comparable results. Primary open arterial reconstructive surgeries are possible in patients with diabetes mellitus as a next step after endovascular surgery or when endovascular surgery can not be done. Conclusion. Similar instant and long-term results were found after direct comparison of bypass and endovascular surgeries, allowing to recommend these surgeries in patients with peripheral vascular disease as a complication of diabetes mellitus.

The effect of antiaggregational therapy on the long-term patency of the femoropopliteal/crural bypass

Antiaggregational therapy can reduce thrombosis development following the arterial reconstruction surgery. In most cases acetylsalicylic acid and ticlopidine are used as antiaggregational agents. The aim of this research was to examine the influence of different antiaggregational agents on a long-term femoropopliteal/crural bypass patency. The study involved 142 patients who underwent femoropopliteal/crural bypass reconstructions at the Cardiovascular Disease Institute of the Clinical Centre of Serbia. Most patient were operated on in the period from December 2007 to December 2009; however, the study also included a certain number of patients who had undergone surgery 1-7 years earlier, and who were postsurgically under a regular check-up and examination. Depending on the administered antiaggregational agents, three groups of the patients were formed: (1) patients on 100 mg/daily acetylsalicylic acid; (2) patients on 2 x 250 mg/daily ticlopidine; and (3) patients on 100 mg/daily acetylsalicylic acid combined with 2x250 mg/daily ticlopidine. Among the formed groups in our study, there was no statistically significant difference in the femoropopliteal/crural bypass long-term patency, and the obtained patency values for each group were in accordance to the data from the literature. The first-choice antiaggregative agent after surgical infrainguinal arterial reconstruction procedures was found to be acetylsalicylic acid as compared to ticlopidin for at least two reasons: low cost and absence of neuthropenia as a side-effect.

The deep veins in arterial reconstructive surgery for limb salvage in patients with multiple occlusions of the femoral and tibioperoneal vessels

Below-knee femoropopliteal and femorodistal bypass with nonautologous material shows poor patency rates, especially in multiple occlusions of the tibioperoneal vessels. Twenty-four patients underwent arterial reconstruction for limb salvage using the deep leg veins because the great saphenous vein was not available owing to previous operations. A follow-up period of forty-two months revealed an average bypass patency rate of 75%. During the control period all patients were prospectively investigated concerning changes in the venous system. The authors found only little changes in the venous system and no significant signs of venous insufficiency. The deep leg veins seem to be a valuable addition to arterial reconstructive surgery for limb salvage.

Assessment of heparin anticoagulation by Sonoclot Analyzer in arterial reconstruction surgery

Since heparin has been in use as an anticoagulant during vascular surgery and medical problems such as DVT or pulmonary embolism, there has been no consensus as to the best method of monitoring its effect on anticoagulation. In this study we used Sonoclot Analyzer to detect hemostasis changes resulting from heparin administration. The study involved 16 randomly selected male patients undergoing peripheral reconstructive surgery. Blood samples were drawn and analyzed in the operating room on the Sonoclot Coagulation and Platelet Function Analyzer. Results showed that patients respond to heparin differently. The Sonoclot monitors the hemodynamics of blood using four variables: SonACT (activated clotting time) time, rate, peak, and contraction rate. Heparin has three effective on the Sonoclot Signature; prolonged ACT result, lower clot rate, and reduction in clot retraction. The SonACT time is the time for first fibrin to form. Prolong this time indicates the presence of anticoagulation. The Sonoclot Analyzer results confirm that it is a reliable and sensitive device for monitoring heparinization levels.