Arterial Access Research Articles

Application of 5% lignocaine patch following radial artery access for the prevention of radial artery occlusion: A novel use

Application of 5% lignocaine patch following radial artery access for the prevention of radial artery occlusion: A novel use

Retrograde Popliteal Artery Access in peripheral Arterial Angioplasty in Management of Superficial Femoral Artery and Proximal Popliteal Artery Occlusive Lesions

Retrograde Popliteal Artery Access in peripheral Arterial Angioplasty in Management of Superficial Femoral Artery and Proximal Popliteal Artery Occlusive Lesions

Evaluation of renal arteries in hypertensive patients by multi-detector computed tomography

Introduction: Among various causes of hypertension, only 1 to 2% is renovascular hypertension which may be characterized by the various reasons in renal vascular supply. Multi-detector computed tomography is used to know about the details of the vascular structures in patients. This study aims to evaluate the renal arteries in hypertensive patients. Methods: A prospective observational study was conducted among 93 hypertensive patients. Contrastenhanced computed tomography of the abdomen and pelvis was conducted, and measurements were obtained from the axial section of the maximum intensity projection image. Data were analyzed using SPSS version 23.0. Independent t-test and Pearson’s Correlation were used. The level of statistical significance was set at p<0.05. Results: The study found mean lengths for the right and left main renal arteries to be 40.33±10.26 mm and 32.36±9.55 mm, and diameters were 4.31±0.86 mm and 4.16±0.81 mm. No significant sex-based differences were observed. However, a significant age-related difference was noted in the length (p=0.012) and diameter (p=0.036) of the right main artery within the 20 to 29 and 80 to 89 years age groups. Weak correlations were observed between left renal artery length and age (r=0.221, p=0.33) and mean right renal artery diameter and age (r=-0.218, p=0.036). Prevalence of accessory renal arteries and early branches was 19.35% and 16.10% respectively. Conclusions: This study found that there were no statistically significant differences in renal arteries dimensions of hypertensive patients with different age groups and genders. Although the proportion of early renal artery branching and accessory arteries are found to be similar to previous studies there may be other associated factors for all hypertensive patients who don’t have early renal branches or accessory arteries.

Bariatric arterial embolization in patients with body mass index ranging from 25 to 40 kg/m2: A systematic review & meta-analysis.

The present review sought to evaluate by meta-analysis the efficacy of bariatric arterial embolization (BAE) in promoting weight loss in patients with body mass index (BMI) ranging from 25-40 kg/m2. This study was performed and reported according to Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines. A systematic literature search of MEDLINE, Embase Google Scholar, and World Health Organization Library database was done for studies evaluating BAE for promoting weight loss in patients with BMI ranging from 25-40 kg/ m2 published up to March 10, 2021. Primary outcome measure included weight loss after the embolisation procedure. Three single-arm studies comprising of a total of 28 patients (BMI: 25- 40 kg/m2) were found eligible for meta-analysis. All patients underwent embolization with either Embosphere microspheres or PVA particles. The predominant artery embolised was left gastric artery (in all patients). Additional arteries embolised included gastroepiploic artery (8 patients), or accessory left gastric artery (1 patient), or short gastric artery (1 patient). Pooled absolute mean weight loss was 7.854 kg (95% CI: 6.103-9.605). No significant statistical heterogeneity was detected (I2=51.75%, P=0.126) among pooled studies. In conclusion, limited single-arm studies report BAE as an effective, and relatively safe procedure for promoting weight loss in patients with BMI ranging from 25-40 kg/m2, although the number of patients included is very small. Initial results of BAE in promoting weight loss are promising with no major/severe complications reported; however, long term follow-up is required to see the sustainability of the effects.

Transradial Access Versus Transfemoral Approach for Carotid Artery Stenting: A Systematic Review and Meta‐Analysis

Background Carotid artery stenting (CAS) has emerged as a viable alternative to carotid endarterectomy for managing carotid artery stenosis in high‐risk patients. Although transfemoral arterial access remains the preferred method, it is associated with inherent limitations and potential complications. Consequently, exploring transradial artery access as a potential option becomes crucial in optimizing patient outcomes and procedural success rates. There are limited data comparing the outcomes of the transradial with the transfemoral approach for CAS. This study aimed to systematically review and meta‐analyze the outcomes and complication rates between transradial and transfemoral access for CAS. Methods A systematic electronic search was conducted in 4 databases. Studies with randomized or nonrandomized designs, involving CAS by the transradial or transfemoral approach, were included. Outcomes of interest were stroke, transient ischemic attack, death, myocardial infarction, and access site complications. A meta‐analysis was performed, analyzing pooled odds ratios (ORs) and 95% CIs to assess the effect size. Results Six studies with a total of 6917 patients were included, of whom 602 (8.7%) underwent the transradial approach and 6315 (91.3%) the transfemoral approach. The meta‐analysis showed no significant difference in stroke occurrence between the transradial and transfemoral groups (transradial:1.7% versus transfemoral:1.9%; OR = 0.98 [95% CI, 0.49–1.96]; I 2 = 0%). Similarly, no significant difference was found in death (TR:1% versus transfemoral:0.9%; OR = 0.95 [95% CI, 0.38–2.37]; I 2 = 0%), myocardial infarction (transradial:0.2% versus transfemoral:0.3%; OR = 1.53 [95% CI, 0.20–11.61]; I 2 = 0%), transient ischemic attack (transradial:0.4% versus transfemoral:1%; OR = 0.46 [95% CI, 0.11–1.95]; I 2 = 0%), or access site complications (transradial:2.2% versus transfemoral:1%; OR = 0.97 [95% CI, 0.48–1.98]; I 2 = 0%). Conclusion No significant differences were observed in stroke, death, myocardial infarction, transient ischemic attack, or access site complications on comparing thetransradial and transfemoral approaches for CAS. The transradial approach shows promise as an alternative method for CAS, offering potential benefits without increased risk of complications. However, further studies are needed to confirm these findings.

Patient and Technical Factors Associated with Difficult Arterial Access and Ultrasound Use in the Operating Room.

Arterial catheterization enables continuous hemodynamic monitoring but has been shown to cause severe complications, especially when multiple attempts are required. The aim of this study was to explore what factors were associated with multiple attempts and ultrasound use in the operating room. We performed a retrospective analysis of patients who had arterial catheters inserted at a tertiary care children's hospital from January 2018 to March 2022, identifying clinical factors that were associated with both outcomes. A total of 3946 successful arterial catheter insertions were included. Multivariable analysis showed multiple attempts were associated with noncardiac surgery: pediatric (OR: 1.79, 95% CI: 1.30-2.51), neurologic (OR: 2.63, 95% CI: 1.89-3.57), orthopedic (OR: 3.23, 95% CI: 2.27-4.55), and non-radial artery placement (OR: 5.00, 95% CI: 3.33-7.14) (all p < 0.001). Multivariable analysis showed ultrasound use was associated with neonates (OR: 9.6, 95% CI: 4.1-22.5), infants (OR: 6.98, 95% CI: 4.67-10.42), toddlers (OR: 6.10, 95% CI: 3.8-9.8), and children (OR: 2.0, 95% CI: 1.7-2.5) compared to teenagers, with cardiac surgery being relative to other specialties-pediatric (OR: 0.48, 95% CI: 0.3-0.7), neurologic (OR: 0.27, 95% CI: 0.18-0.40), and orthopedic (OR: 0.38, 95% CI: 0.25-0.58) (all p < 0.001). In our exploratory analysis, increased odds of first-attempt arterial catheter insertion success were associated with cardiac surgery, palpation technique, and radial artery placement. Younger patient age category, ASA III and IV status, cardiac surgery, and anesthesiologist placement were associated with increased odds of ultrasound use.

Challenges associated with vascular access through the common carotid artery during embalming procedures in humans: A technical note.

The teaching of anatomy is a key component in the training of physicians, and the foundation of this teaching is the human body, which must be properly prepared to be used as a teaching aid. Due to a lack of modern literature on this topic, we decided to write a technical note discussing access to the carotid artery. We pre-qualified 43 donor bodies for the study. The bodies had to meet standards such as no signs of post-mortem decomposition, preservation of body integrity, and the absence of known infections. Carotid artery access was performed based on descriptions of the types of vascular access performed in surgery and our own observations. We consider carotid artery access to be a convenient option due to its ease of location. When performed correctly and with attention to the surrounding structures, it is relatively low in tissue trauma, which translates into a higher quality of preparation. Data analysis has revealed several factors that can have a significant impact on the success of the embalming procedure. Proper execution of minimally invasive access to the common carotid artery minimizes tissue damage and ensures a high success rate of the procedure. Knowledge of the types of vascular access is essential for preparing the highest quality specimens.

Comparison of GRACE Score and SYNTAX Score in Predicting Complexity of Coronary Artery Disease in Patients with NST-ACS

Objective: To compare the GRACE score and SYNTAX score in predicting Coronary Artery Disease (CAD) severity and the variation of GRACE score with respect to SYNTAX score to assess severity of CAD. Study Design: Analytical, Cross-sectional study. Place and Duration of Study: Armed Forces Institute of Cardiology/National Institute of Heart Diseases, Rawalpindi Pakistan, from Jan 2023 to Jun 2023. Methodology: Data was gathered from n=139 participants by using consecutive sampling technique on a data collection tool.Study variables such as demographics, comorbids, clinical characteristics and SYNTAX and GRACE score were noted to asses their role in determining CAD severity. An experienced cardiologist was assigned to analyze the coronary angiogram findings, performed by using conventional techniques through radial artery, ulnar or femoral artery access. SPSS version-24.00 was used for data management and analysis. Chi square test and Pearson correlation was applied to find the association and correlation respectively. Results: Mean age of study participants was 62.09±9.74 years and males were more in number 114(82.0%). Ninety three (66.9%) patients had NSTEMI. Gender (p=0.011,0.007), was significantly associated with SYNTAX score as well as GRACE score respectively and diabetic status (p=0.003) with GRACE score. There was a strong and positive correlation between GRACE score and SYNTAX score (r=0.64; p&lt;0.001). Both scores showed significant association with CAD severity (p&lt;0.05). Conclusion: There exists a statistically significant and positive correlation between GRACE score and SYNTAX score in non-ACS (NSTEMI and UA) patients who had confirmed diagnosis of CAD on coroangiogram. The greater the GRACE score, the greater was........

Comparison of ultrasound- versus fluoroscopy-guidEd femorAl access In tranS-catheter aortic valve replacement In the Era of contempoRary devices: The EASIER registry

BackgroundVascular complications (VCs) still represent one of the principal concerns of trans-femoral trans-catheter aortic valve replacement (TF-TAVR). New-generation devices can minimize such complications but the arterial access management is left to the operator's choice. This study aims to describe the rate of VCs in a contemporary cohort of patients undergoing TAVR with new-generation devices and to determine whether an ultrasound-guided (USG) vs. a fluoroscopy-guided (FG) femoral access management has an impact on their prevention. MethodsThis is a prospective, observational, multicenter study. Consecutive patients undergoing TAVR with new-generation devices were analyzed from January 2022 to October 2022 in five tertiary care centers. Femoral accesses were managed according to the operator's preferences. All the patients underwent a pre-discharge peripheral ultrasound control. VCs and bleedings were the main endpoints of interest. ResultsA total of 458 consecutive patients were enrolled (274 in the USG group and 184 in the FG group). VCs occurred in 6.5 % of the patients (5.2 % minor and 1.3 % major). There was no difference between the USG and the FG groups in terms of any VCs (7.3 % vs. 5.4 %; p = 0.4), or any VARC-3 bleedings (6.9 % vs 6 %, p = 0.9). At logistic regression analysis, the two guidance strategies did not result as predictors of VCs (odds Ratio 0.8, 95 % Confidence Interval 0.46–1.4; P = 0.4). ConclusionsIn a contemporary cohort of patients undergoing TAVR with new-generation devices, the occurrence of VCs is low and mostly represented by minor VCs. USG and FG modalities did not affect the rate of VCs.

Endovascular interventions from distal radial access on the back of the left hand in emergency surgical practice

In urgent surgical practice with bleeding of various genesis, when the question of endovascular hemostasis arises, it is crucial to choose the safest arterial access, in which specific vascular complications will be minimal. Reducing the likelihood of hemorrhagic complications in the arterial access during X-ray endovascular surgery is an essential aspect, especially with a high degree of blood loss. The possibility of using distal radial access with localization on the back of the left hand for endovascular interventions in emergency surgery is discussed in this article.

Combined venous and arterial access in the arm for treatment of a complex dural arteriovenous fistula: a technical video.

Transvenous access is a necessary tool for numerous cerebrovascular pathologies.Transvenous access in the arm offers several benefits compared with transfemoral access, including patient comfort, the avoidance of transfemoral access complications, and the ability to close both radial arterial access and distal arm venous access with a single transradial compression band.1In this video we describe the indications, technical nuances, benefits, and limitations of transvenous access in the arm.neurintsurg;jnis-2023-020996v1/V1F1V1Video 1- Combined venous and arterial access in the arm for treatment of a complex dural arteriovenous fistulaWe present the case of a young patient who presented with pulsatile tinnitus and was found to have a Cognard type IIa dural arteriovenous fistula near the left transverse sigmoid junction.The patient was treated with transvenous embolization via the distal right basilic vein, and a single radial compression band served to close both the arterial and venous access sites.

Selective aortic arch perfusion: a first-in-human observational cadaveric study

BackgroundSelective aortic arch perfusion (SAAP) is a novel endovascular technique that combines thoracic aortic occlusion with extracorporeal perfusion of the brain and heart. SAAP may have a role in both haemorrhagic shock and in cardiac arrest due to coronary ischaemia. Despite promising animal studies, no data is available that describes SAAP in humans. The primary aim of this study was to assess the feasibility of selective aortic arch perfusion in humans. The secondary aim of the study was to assess the feasibility of achieving direct coronary artery access via the SAAP catheter as a potential conduit for salvage percutaneous coronary intervention.MethodsUsing perfused human cadavers, a prototype SAAP catheter was inserted into the descending aorta under fluoroscopic guidance via a standard femoral percutaneous access device. The catheter balloon was inflated and the aortic arch perfused with radio-opaque contrast. The coronary arteries were cannulated through the SAAP catheter.ResultsThe procedure was conducted four times. During the first two trials the SAAP catheter was passed rapidly and without incident to the intended descending aortic landing zone and aortic arch perfusion was successfully delivered via the device. The SAAP catheter balloon failed on the third trial. On the fourth trial the left coronary system was cannulated using a 5Fr coronary guiding catheter through the central SAAP catheter lumen.ConclusionsFor the first time using a perfused cadaveric model we have demonstrated that a SAAP catheter can be easily and safely inserted and SAAP can be achieved using conventional endovascular techniques. The SAAP catheter allowed successful access to the proximal aorta and permitted retrograde perfusion of the coronary and cerebral circulation.

Transcatheter Ventricular Septal Defect Closure with Lifetech™ Konar-MF Occluder in Infants Under 10kg with Only Using Venous Access.

Transcatheter closure of VSD remains a complex procedure in infants with technical challenges and carries the risk of significant complications, due to its complex anatomical morphology and closed proximity to the atrioventricular valves and the conduction system. In this article, we presented transcatheter VSD closure in infants under 10kg using the Lifetech Konar-MF device via only venous route without TEE guidance and arterial access. Between January 2021 and May 2023, a total of 34 patients weighing less than 10kg who underwent transcatheter VSD closure antegradely with Lifetech™ Konar-Multifunctional (MF) occluder were included in the study. The mean age of the patients was 8.1 (3.5-35) months. Average weight was 6.5kg (range 4.5-10kg). VSD was perimembranous in 27 patients (79.4%). Successful device placement was achieved in all 34 patients. However, device embolization occurred in three patients. One of the patients was successfully implanted with a one size larger device, the surgical closure was performed other two cases. TR occurred in seven patients (20.6%) after releasing devices. None of the patients developed complete heart block. Right bundle branch block developed in two patients. Residual shunt was observed in 9 patients (six small, two moderate, and one large). During follow-up, residual shunt disappeared in six of these patients and only mild residual shunt remained in the other four patients which have not required any further intervention. Transcatheter closure of VSD with Lifetech Konar-MF device is safe and effective in infants less than 10kg via only venous access with a high success rate and low complication rate. In these patients, transcatheter VSD closure can be performed by excluding the risk of complications that may occur due to AV loop formation, arterial intervention, endotracheal intubation and TEE use.

Real-time ultrasound-guided hemostasis using suture-mediated closure device.

Suture-mediated hemostasis device takes a long time to train and have limitations in finding appropriate compression point depending on the tactile sense of the hands. If the appropriate compression point is determined using ultrasound and the instrument is used under ultrasound guidance, it is expected to reduce the technical failure and additional manual compression. This retrospective study included 104 patients in whom the ProGlide vascular closure device (Abbott Vascular, Redwood City, CA, USA) was deployed to close common femoral artery access between January 2022 and June 2022. Ultrasound-guided hemostasis was performed in 54 patients and 50 conventional hemostasis was performed. We analyzed the medical records (procedure, patient body mass index, coagulation function, visual imaging, ultrasound imaging, time to achieve hemostasis) and post-treatment medical records (progress records, nursing records) to investigate the technical success rate and complications (hematoma, pseudoaneurysm formation, SFA occlusion, access site infection) of the procedure. Technical success rate was 52/54 (Ultrasound guided group) and 47/50 (conventional group), respectively (p > 0.05). Mean hemostasis time was 271 s (US guided group) and 317 s (conventional group), respectively (p > 0.05). Additional manual compression was applied in 7/54 (US guided group) and 15/50 (conventional group) (p < 0.05). In both groups, complications such as hematoma formation, access site infection and SFA occlusion did not occur. Using ultrasound guidance when using the suture mediated closing device reduces the frequency of additional manual compression without increased risk of complication.

An Unusual Anatomical Variation of Accessory Left Gastric Artery Arising from Left Hepatic Artery

An Unusual Anatomical Variation of Accessory Left Gastric Artery Arising from Left Hepatic Artery

Radial artery spasms impair invasive cardiological procedures' performance: a pharmacological approach to prevention and treatment.

The radial artery (RA) access is currently the gold standard to perform cardiovascular interventions. One of the more common limitations is radial artery spasm which is an often complication interrupting the procedure. Common risk factors associated with spasm include female gender, periprocedural anxiety, multiple puncture attempts, distal radial access, diabetes, hypertension, and smoking. The mechanism of spasm is complex and includes calmodulin and rho-kinase pathways leading to the smooth muscle contraction. Proper hydration, anxiety management, and adequate local anesthesia should be applied to decrease the risk of spasms. Radial cocktail is often used to prevent spasm. Its composition differs between catheterization laboratories and the effect is attributed either to the verapamil or nitroglycerin, with contradictory results of different studies. Balbay maneuver is also an effective mean of prevention. Hydrophilic-coated devices can be used both to avoid spasms or reverse them. Radial angiography can be used to differentiate spasm from a tortuosity and choose proper method of management. Fasudil, a Rho-kinase inhibitor, has been reported as a pharmacological method to prevent spasm and reverse radial artery spasm.

Covering the intercostal artery branching of the Adamkiewicz artery during endovascular aortic repair increases the risk of spinal cord ischemia

ObjectivesThis study aimed to determine the relationship between covering the intercostal artery branching of the Adamkiewicz artery (ICA-AKA) and spinal cord ischemia (SCI) during thoracic endovascular aortic repair (TEVAR). MethodsPatients who underwent TEVAR from 2008 to 2022 were enrolled. Stent grafts covered the ICA-AKA in 108 patients (covered AKA group) and stent grafts didn’t cover the ICA-AKA in 114 patients (uncovered AKA group). The characteristics of 58 patients from each group were matched based on propensity scores. ResultsNo significant differences in SCI rates were detected between the covered AKA (10%; 11/108) and uncovered AKA (3.5%; 4/114) groups (P = .061). Shaggy aorta (odds ratio [OR], 5.16; 95% confidence interval [CI], 1.74-15.3, P = .003), iliac artery access (OR, 6.81; 95% CI, 2.22-20.9, P = .001), and procedural time (OR, 1.01; 95% CI, 1.00-1.02, P = .003) were risk factors for SCI in the entire cohort. Although covering the ICA-AKA (OR, 2.60; 95% CI, 0.86-7.88, P = .058) was not a significant risk factor, shaggy aorta (OR, 8.15; 95% CI, 2.07-32.1, P = .003), iliac artery access (OR, 9.09; 95% CI, 2.22-37.2, P = .002), and procedural time (OR, 1.01; 95% CI, 1.01-1.02, P = .008) were risk factors for SCI in the covered AKA group. No significant risk factors were detected in the uncovered AKA group. ConclusionsCovering the ICA-AKA was not an independent risk for SCI in TEVAR. However, covering the ICA-AKA was indirectly associated with the risk of SCI in patients with shaggy aorta, iliac access, and procedural time.

Anatomical Distribution Patterns of Peripheral Arterial Disease in the Upper Extremities According to Patient Characteristics: A Retrospective Cohort Study.

Peripheral arterial disease (PAD) greatly affects the patients' quality of life. We aimed to investigate the affected anatomical sites and distribution patterns in upper extremity PAD using computed tomography angiography (CTA). Furthermore, we sought to identify the correlations between patient characteristics and the identified patterns. This was a retrospective chart review of upper limb CTA findings from patients with symptomatic PAD aged >18 years. Significant variables from univariate logistic regression analysis were further tested using multivariate logistic regression analysis. Statistical significance was set at p < 0.05, with confidence intervals of 95%. The mean age of the 102 included patients with upper extremity PAD was 55.45 years. Laterality analysis revealed that the upper left limb segments were more affected than the upper right limb segments (42 vs 63; left-to-right ratio, 3:2). The forearm was the segment most affected by stenotic PAD (62 segments, 3.37%). The arm was the segment most affected by occlusive PAD (14 segments, 0.76%). Diabetes mellitus (DM) and hypertension (HTN) were significant predictors of PAD (p = 0.046). In patients with DM, the occlusive form of PAD was dominant in the arm (18.18%); however, the stenotic form prevailed in the forearm (72.72%). In patients with HTN, the occlusive form of PAD was predominant in the arm (45.45%); however, the stenotic form tended to occur in the arm and forearm (90.90%). The distribution patterns of upper extremity PAD are linked to its underlying pathophysiology. HTN and DM are the most frequent comorbidities in patients with upper extremity PAD. Angiographically, PAD in these patients is likely to present as stenosis rather than as occlusion. This is vital for interventionists who deviate from radial arterial access in patients with PAD. Therefore, targeted screening standards are required, and further studies on PAD are warranted.

Open Radial Artery Study

Radial artery occlusion (RAO) has been the most common postprocedural complication of transradial artery access. The optimal method of prevention of RAO is still lacking. In our study, we aimed to evaluate the effect of patent hemostasis on early (24hours) and late (2weeks) RAO prevention. The Open Radial Artery Study was a single-arm, prospective, and multicenter study. The primary end points were early and late RAO at the vascular access site after transradial coronary procedures. Secondary end points were access site hematoma, pseudoaneurysm formation, arteriovenous fistula, and nerve injury. A total of 2,181 patients were analyzed (67% male, mean age 68years). The mean interventional duration and hemostatic times were 75.6 ± 55.6 and 60 ± 5.6minutes, respectively. Radial artery spasm occurred in 10% of patients (n=218). Catheter kinking, radial artery rupture, or dissection were not observed during the procedure. RAO, hematoma, pseudoaneurysm, arteriovenous fistula, or nerve damage was not observed in any of the patients in the early or late period. In patients who undergo coronary diagnostic or interventional procedures through transradial artery access, the patent hemostasis method seems a critical step in the prevention of early and late RAO.

Three-dimensional Computed Tomography Evaluation of the Vasculature of Right-side Colon Cancer.

From an oncological perspective, central ligation of the feeding vessel is an important approach to consider when performing colon cancer surgery. This study aimed to use three-dimensional computed tomography (3D-CT) to clarify the vascular anatomy for performing central vascular ligation to improve the accuracy of minimally invasive surgery (MIS) performed to treat advanced right-side colon cancer. This descriptive study was conducted at one institution and targeted 92 patients with right-side colon cancer whose vascular anatomy was evaluated with 3D-CT before surgery between January 2014 and December 2020 at Tokyo Medical University Hospital. In 49 patients (53.3%), the ileocolic artery was ventral to the superior mesenteric vein (SMV), whereas in 43 patients (46.7%), it was dorsal to the SMV. The right colic artery was present in 31 patients (33.7%). The middle colic artery was present in all patients (100%). A common duct type was present in 80 patients (87.0%). Branching directly from the superior mesenteric artery without a common duct was observed in 12 patients (13.0%). Twenty-one patients (22.9%) had an accessory superior mesenteric artery. The vascular structure of the right-side colon is highly complex. Conducting 3D-CT evaluations of the vessel anatomy is very useful for surgeons who conduct MIS, and is considered to enable central ligation to be performed safely and improve the quality of surgery, which will benefit patients.