Artery Clamping Research Articles

Bilateral Ligation of the Anterior Branch of the Hypogastric Artery in Massive Obstetric Hemorrhage Secondary to Septic Abortion (Case Report)

Hemorrhage is the main cause of Maternal Mortality (MM) (27%) followed by hypertensive disorders and sepsis (12%). Septic abortion is considered an intermediate risk factor for the development of Massive Obstetric Hemorrhage (MOH). The algorithm for the management of postpartum hemorrhage due to uterine atony that includes systematic pelvic devascularization has been described, but this management is really planned for resolution of the pregnancy after the 20th week of gestation, since an HMO due to abortion is un usual. We present the case of a 21-year-old patient who self-medicates a prostaglandin analog at 2 months of pregnancy, achieving only a threat of abortion, goes to the emergency room 3 months later with a diagnosis of septic shock, USG and MRI are performed with altered results, only of hepatomegaly, delayed abortion of 8 weeks of evolution and gestational trophoblastic disease. Emergency MVA was performed due to profuse bleeding, placement of a Bakri balloon and clamping of the uterine arteries without results, for which an emergency exploratory laparotomy (LAPE) was performed with ligation of the anterior trunk of the internal iliac artery, being a successful procedure, without the need for Obstetric Hysterectomy (HO). The patient is managed in intensive care and in the end the diagnosis of TSG is ruled out. Bilateral Hypogastric Artery Ligation (BHAL) in the case of Massive Obstetric Hemorrhage (MOH) secondary to delivery or cesarean section is commonly used, however it is not a technique to report when bleeding is secondary to abortion. In these cases, it is also a viable, successful, fertility-preserving surgical procedure, and an alternative to Obstetric Hysterectomy (OH) when other less invasive methods such as uterine artery clamping or Bakri balloon have failed.

Apigenin Nanoparticle Attenuates Renal Ischemia/Reperfusion Inflammatory Injury by Regulation of miR-140-5p/CXCL12/NF-κB Signaling Pathway.

Apigenin as a natural flavonoid product has been proved previously to play a renoprotective effect during ischemia/reperfusion injury (IRI), but the particular mechanisms involving the positive effects of apigenin remain totally unclear. The study investigated apigenin's roles and underlying biological mechanisms in IR-induced acute kidney injury (AKI). Thirty-six mice received a right nephrectomy and clamping of the left renal artery for 30 minutes, and then perfusion for 24 h. Apigenin was loaded onto a biodegradable polymer carrier (nanoparticle) to enhance its bioavailability. Mice were subjected to intraperitoneally injection with apigenin (5, 10 or 20 mg/kg) for 24 h before surgery. For in vitro experiments, mouse renal tubular epithelial cells (mRTECs) and miR-140-5p mimic/inhibitor transfected mRTECs were subjected to hypoxia/reoxygenation in the presence or absence of apigenin. In vitro, we uncovered that hypoxia/reoxygenation stimulation caused inflammatory injury in mRTECs. Apigenin reduced the hypoxia/reoxygenation-induced cell inflammatory injury and NF- B p65 nuclear translocation from cytoplasm and activation. Moreover, apigenin reduced hypoxia/reoxygenationtriggered miR-140-5p down-regulation. What's more, the luciferase reporter system revealed that miR-140-5p negatively regulates CXCL12, which is its direct target of action. CXCL12 exhibited an inhibitory effect on the apigenin-induced inactivation of NF- B signaling pathway. Furthermore, we observed that apigenin pretreatment attenuated the IR-triggered up-regulation of serum creatinine and blood urea nitrogen, elevation of pro-inflammatory cytokines secretion and tubular cell apoptosis, enhancement of CXCL12 and decline of miR-140-5p in vivo. Our studies show that apigenin protects against IR-triggered renal cell inflammatory injury in vivo and in vitro by miR-140-5p up-regulation and CXCL12 downregulation via quenching the NF- B pathway activation. Apigenin may be an encouraging therapeutic agent for patients with IR-associated kidney injury.

Effects of Sevoflurane and Propofol Anesthesia on Cerebral Oxygenation in Patients Undergoing Carotid Endarterectomy.

To compare the effects of sevoflurane and propofol anesthesia on perioperative cerebral oxygenation in patients undergoing carotid endarterectomy (CEA) under general anesthesia by using near-infrared spectroscopy (NIRS) monitoring. Institutional approval was obtained, and the perioperative data of 33 patients undergoing CEA were retrospectively evaluated. The study groups were organized according to the anesthesia drugs used for maintenance: sevoflurane (n=17) and propofol (n=16). The regional cerebral oxygen saturation (rScO < sub > 2 < /sub > ) of the ipsilateral and contralateral hemispheres was monitored continuously using a NIRS instrument and analyzed at specific time points starting from induction to the 12th hour postoperation. The data were analyzed using the appropriate tests, and a p value of < 0.05 was considered significant. Compared with those of groups with non-clamped hemispheres, the rScO < sub > 2 < /sub > values of the sevoflurane and propofol groups decreased significantly during clamping (p < 0.05) and increased to above-preoperative values after declamping (p < 0.05). When the sevoflurane and propofol groups were compared, a significant decrease in rScO < sub > 2 < /sub > was noted during extubation in the sevoflurane group (p < 0.05). In the propofol group, female patients had significantly lower rScO < sub > 2 < /sub > values compared with male patients during clamping of the carotid artery (p < 0.05). None of the observed decreases was greater than 20%, which is considered an indication for shunting. Our NIRS monitoring results indicate that sevoflurane or propofol anesthesia does not generally cause significant differences in cerebral oxygenation during and after cross-clamping in patients undergoing CEA. The finding of sex-related differences in cerebral oxygenation in patients receiving propofol and decreased oxygenation during extubation in patients receiving sevoflurane warrants further studies.

How I divide the liver parenchyma - robotic technique

Presenter: Marcel Autran Machado MD | Nove de Julho Hospital Background: Surgical resection is the only curative modality of treatment in patients with primary and secondary liver resections. However, blood loss remains a significant factor affecting prognosis. The development of bloodless techniques to facilitate surgical resection of liver tumors has stimulated HPB surgeons. Methods: The authors have devised a technique to perform a bloodless liver transection without any suture or ligature on the raw surface of the liver and without the need of any expensive and/or sophisticated devices during robotic liver resections. The bipolar forceps with saline irrigation under selective hepatic artery clamping is the key to achieve a bloodless raw liver area. Some video extracts are included to better illustrate the technique and its ability to control major hepatic veins and portal pedicles. Results: We have successfully used this technique in our robotic liver resection since 2018. It may preclude the use of staplers thus reducing operating costs. Conclusion: The present technique of robotic liver transection is safe and bloodless.

Temporary Mesenteric-Portal Shunt Using Prosthetic Graft Together with Intermittent Superior Mesenteric Artery Clamping (Pringle-Like) during Complex Venous Resction/Reconstruction in Pancreaticoduodenctomy for Locally Advanced Pancreatic Tumours

Introduction: Portal and superior mesenteric vein resection and reconstruction during pancreatic surgery for locally advanced tumors poses a challenging surgical scenario. Potential problems are; major bleeding, prolonged clamping with hepatic ischemia, venous congestion of the gut, and using the more difficult artery first approach. This potentially may increase morbidity and mortality of the procedure. To obviate these potential problems, we propose a pre-emptive temporary SMV-portal venous shunt with intermittent SMA clamping (pringle-like).

FREEZE-DRIED PLATELET-RICH PLASMA PROMOTES TRIGEMINAL NEUROPATHIC PAIN RELIEF IN A RAT MODEL

Objective: Neuropathic pain and treatment side effects decreasing quality of life, reducing productivity, and high costs due to long duration of treatment. Regenerative medicine is a new and effective alternative treatment for neuropathic pain, one of which is Platelet-Rich Plasma (PRP) therapy. The objective if this study is to prove that there are differences in neuroregeneration post-crush injury after FD-PRP administration. Materials and Methods: Neuropathic pain model was made with crushing method, by compressing the infraorbital nerve using the artery clamp for 15 seconds. Rats divided into six groups. Each group was observed on day 14 (A, B, C) and 21 (A', B', C') to observe the macrophages, lymphocytes, and Schwann cells with Hematoxylin Eosin staining seen on horizontal plane of the infraorbital nerve with 400x magnification. Face grooming observations were performed on day 0 (A0, B0, C0), day 7 (A7, B7, C7), day 14 (A14, B14, C14), day 21 (A21, B21, C21). Results: There were significant differences in face grooming frequencies between groups on day 0 (p = 0.002). ANOVA Same Subject test on A`, B`, and C` revealed significant differences in macrophages and lymphocytes with score 0.02 (p &amp;lt;0.05) and 0.013 (p&amp;lt;0.05), respectively. There were significant differences between group A' and B' and between B' and C' (p&amp;gt;0.05). Conclusions: FD-PRP promotes nerve regeneration in axonotmesis, which was characterized by a decrease in face grooming frequency on day 7 and an increase in the number of lymphocytes, macrophages and Schwann cells on day 21.

Open Surgical Repair for a Giant Common Hepatic Artery Aneurysm with Difficulty in Proximal Arterial Clamping: A Case Report.

Hepatic artery aneurysm has been considered as a rare, life-threatening disease. In this study, we report on a patient requiring surgical treatment for a giant hepatic artery aneurysm by aneurysmectomy without revascularization. A 70-year-old woman who complained of epigastric pain was referred to our hospital. Enhanced computed tomography scan has revealed a giant (11×9 cm) common hepatic artery aneurysm. She then underwent emergency surgery; the intra-aortic balloon occlusion technique was applied in order to control the blood inflow into the aneurysm. The aneurysm was then incised, and direct closure of the inflow and outflow orifices was performed safely without evidence of ischemic change in the liver.

Role of Doppler Ultrasound Analysis of Blood Flow Through the Ophthalmic and Intracranial Arteries in Predicting Neurologic Symptoms During Carotid Endarterectomy.

Carotid endarterectomy (CEA) is frequently performed under locoregional anesthesia. The intraoperative clamping of the internal carotid artery (ICA) leads to cerebral hypoperfusion, which may in some patients result in the development of neurologic symptoms (NS). The objective of our study was to investigate whether there is an association between the preoperative ultrasound (US) Doppler flow in the ophthalmic artery (OA) and intracranial artery and the occurrence of these intraoperative NS. We compared 50 patients with NS and 150 patients without NS during CEA. We analyzed their preoperative blood flow characteristics by Doppler US and their clinical and demographic characteristics. The contralateral ICA occlusion increased the likelihood of intraoperative NS (odds ratio [OR], 8.4; P < .001). Abnormal contralateral OA flow also increased the likelihood of NS (OR, 1.84; P < .001), whereas ipsilateral abnormal OA flow reduced it (OR, 0.73; P=.06). Increased flow in the ipsilateral anterior cerebral artery (ACA) increased the likelihood of NS (OR, 3.3), whereas reversed flow decreased it (OR, 0.1; P=.03). Inverse flow in the contralateral ACA increased the risk (OR, 5.4), whereas increased flow reduced it (OR, 0.2; P=.02). Male patients had a higher risk of NS (P=.09) as well as older patients (P=.05). Eight percent of the patients with NS developed a transient ischemic attack or stroke. Doppler US analysis of the OA and ACA in combination with analysis of ICA stenosis may be a promising predictor of NS during ICA clamping. This, in turn, may warn the patient and the surgeon of an increased risk during surgery.

Cilostazol mitigates mesenteric ischemia/reperfusion-induced lung lesion: Contribution of PPAR-γ, NF-κB, and STAT3 crosstalk

AimsCilostazol (Cilo), a phosphodiesterase-III inhibitor, has signified its efficacy against different ischemia/reperfusion (IS/RE) models. Nevertheless, it has not fully illuminated its potential effect against intestinal IS/RE-induced lung injury. Consequently, the study was fashioned to evaluate the feasible mechanism of action of Cilo against intestinal IS/RE-induced lung injury. Main methodsWistar rats were treated with Cilo (0.1 g/kg, p.o.) or with a vehicle for 14 days prior to IS/RE, induced by clamping of the superior mesenteric artery for 30 min with subsequent clamp removal for 2 h. Key findingsThe mechanistic study disclosed that Cilo protected the two studied organs, viz., lung, and intestine partially by intensifying the expression/content of PPAR-γ accompanied by reducing the expression/content of NF-қB-p65 and STAT3. In addition to normalizing MDA, iNOS, and NOx, the Cilo antioxidant power was confirmed by intensifying tissues content of the total antioxidant capacity. With regard to the anti-inflammatory effect, Cilo reduced the effects of TNF-α, IL-6, and ICAM-1, which were reflected in MPO activity. Furthermore, Cilo had an anti-apoptotic attribute demonstrated by enhancing Bcl-2 content and lessening caspase-3 level. SignificanceCilo provided conceivable protective mechanisms to modulate events concomitant with mesenteric IS/RE partly by modulating oxidative stress, inflammation, and apoptosis feasibly via the participation of PPAR-γ, STAT3, and NF-κB p65 signaling pathways.

Feasibility of fresh frozen human cadavers as a research and training model for endovascular image guided interventions.

To describe the feasibility of a fresh frozen human cadaver model for research and training of endovascular image guided procedures in the aorta and lower extremity. The cadaver model was constructed in fresh frozen human cadaver torsos and lower extremities. Endovascular access was acquired by inserting a sheath in the femoral artery. The arterial segment of the specimen was restricted by ligation of collateral arteries and, in the torsos, clamping of the contralateral femoral artery and balloon occlusion of the supratruncal aorta. Tap water was administered through the sheath to create sufficient intraluminal pressure to manipulate devices and acquire digital subtraction angiography (DSA). Endovascular cannulation tasks of the visceral arteries (torso) or the peripheral arteries (lower extremities) were performed to assess the vascular patency of the model. Feasibility of this model is based on our institute's experiences throughout the use of six fresh frozen human cadaver torsos and 22 lower extremities. Endovascular simulation in the aortic and peripheral vasculature was achieved using this human cadaver model. Acquisition of DSA images was feasible in both the torsos and the lower extremities. Approximately 84 of the 90 target vessels (93.3%) were patent, the remaining six vessels showed signs of calcified steno-occlusive disease. Fresh frozen human cadavers provide a feasible simulation model for aortic and peripheral endovascular interventions, and can potentially reduce the need for animal experimentation. This model is suitable for the evaluation of new endovascular devices and techniques or to master endovascular skills.

Noninvasive Monitoring of Deep Tissue Oxygenation in Buried Flaps by Time-Resolved Near-Infrared Spectroscopy in Pigs.

Flap monitoring in reconstructive surgery is particularly important because flap failure is a dramatic event for the patient and for the medical team. Noninvasive deep tissue oxygenation monitoring is a challenge. The aim of this experimental study was to assess the performance of time-resolved near-infrared spectroscopy compared with continuous-wave near-infrared spectroscopy and with invasive oxygen partial pressure measurement in pigs. Thirty fasciocutaneous flaps based on the superficial epigastric inferior pedicle were harvested and buried under the transcutaneous dorsal muscle (approximately 1 cm thick). An optical probe was placed on the skin above each buried flap. For each pig, two buried flaps were performed, one submitted to arterial occlusion and one to venous occlusion. Oxyhemoglobin and deoxyhemoglobin concentrations were observed for over 40 minutes before clamping, almost 20 minutes during clamping and during a period of release of approximately 20 minutes. Variations in time-resolved near-infrared spectroscopy were compared to the oxygen partial pressure and continuous-wave near-infrared spectroscopy variations. All vascular events were detected by the time-resolved near-infrared spectroscopy. During arterial clamping, oxyhemoglobin decreased rapidly, whereas deoxyhemoglobin increased moderately. The divergence of oxyhemoglobin and deoxyhemoglobin curves indicated arterial occlusion. During venous clamping, deoxyhemoglobin increased, whereas oxyhemoglobin increased briefly then remained stable or decreased moderately. The initial increases in the oxyhemoglobin and deoxyhemoglobin curves indicated venous occlusion. Oxygen partial pressure failed to detect vascular events in three cases. Continuous-wave near-infrared spectroscopy could not clearly identify vascular occlusions. Thus, the authors demonstrated the relevance of time-resolved near-infrared spectroscopy to buried flap monitoring. Time-resolved near-infrared spectroscopy could differentiate between arterial occlusion and venous occlusion.

Increased Succinate Accumulation Induces ROS Generation in In Vivo Ischemia/Reperfusion-Affected Rat Kidney Mitochondria.

Mitochondria are recognized as main reactive oxygen species (ROS) producers, involving ROS generation by mitochondrial complexes I and III. Lately, the focus has been shifting to the ROS generation by complex II. Contribution of complex II (SDH) to ROS generation still remains debatable, especially in in vivo settings. Moreover, it is not completely defined at what time of ischemia the first alterations in mitochondria and the cell begin, which is especially important with renal arterial clamping in vivo during kidney surgery, as it predicts the postischemic kidney function. The aim of this study on an in vivo rat kidney ischemia/reperfusion model was to determine if there is a connection among (a) duration of kidney ischemia and mitochondrial dysfunction and (b) succinate dehydrogenase activity, succinate accumulation, and ROS generation in mitochondria at low and saturating succinate concentrations. Our results point out that (1) mitochondrial disturbances can occur even after 30 min of kidney ischemia/reperfusion in vivo and increase progressively with the prolonged time of ischemia; (2) accumulation of succinate in cytosol after ischemia/reperfusion correlated with increased H2O2 generation mediated by complex II, which was most noticeable with physiological succinate concentrations; and (3) ischemia/reperfusion induced cell necrosis, indicated by the changes in LDH activity. In conclusion, our new findings on the accumulation of succinate in cytosol and changes in SDH activity during kidney ischemia/reperfusion may be important for energy production after reperfusion, when complex I activity is suppressed. On the other hand, an increased activity of succinate dehydrogenase is associated with the increased ROS generation, especially with physiological succinate concentrations. All these observations play an important role in understanding the mechanisms which occur in the early phase of ischemia/reperfusion injury in vivo and may provide new ideas for novel therapeutic approaches or injury prevention; therefore, more detailed studies are necessary in the future.

Distinction between arterial and venous occlusion with tissue oxygen pressure in a porcine fascio-cutaneous flap model.

In recent years, many devices have been developed to monitor free flaps. The Licox probe, which measures tissue oxygen pressure (PtO2 ), is one of the available devices. Our aim was to demonstrate that PtO2 could distinguish arterial from venous occlusion in a porcine fascio-cutaneous flap model. Twenty pigs (Sus scrofa domestica, Youna strain, males) were included in this study. The median weight was 87.6 kg (84.6-90.8). Bilateral fascio-cutaneous flaps based on the superficial inferior epigastric pedicle were harvested from each pig. Thirty-eight flaps were analyzed in this study and were monitored by a Licox system during vascular occlusion. The flaps were randomized into two groups according to the clamped vessel: the arterial group (n = 19) and the venous group (n = 19). After a stabilization period of almost 40 min, vascular clamping (arterial or venous) was performed using a microvascular clamp for almost 20 min. The curve profiles were compared between arterial and venous occlusion. The inflection point was reached significantly faster in the arterial group: 11 min (9-16) for arterial clamping and 17 min (13-23) for venous clamping (p = .001). A total of 18/19 (95%) pigs in the arterial group and 13/19 (68%) in the venous group (p = .09) reached a level lower than 10 mmHg. The median duration for pressure to drop below 10 mmHg was 9 min (6-12) for arterial clamping and 10 min (9-16) for venous clamping (p = .06). We showed that PtO2 decreased faster in cases of arterial occlusion than in cases of venous occlusion in a pig model. Based on this observation, it may be possible to distinguish arterial from venous occlusion.

Pre-Operative Fasting Provides Long Term Protection Against Chronic Renal Damage Induced by Ischaemia Reperfusion Injury in Wild Type and Aneurysm Prone Fibulin-4 Mice

Renal ischaemia reperfusion injury (IRI) is inevitable during open repair of pararenal aortic aneurysms. Pre-operative fasting potently increases resistance against IRI. The effect of fasting on IRI was examined in a hypomorphic Fibulin-4 mouse model (Fibulin-4+/R), which is predisposed to develop aortic aneurysms. Wild type (WT) and Fibulin-4+/R mice were either fed ad libitum (AL) or fasted for two days before renal IRI induction by temporary clamping of the renal artery and vein of both kidneys. Six hours, 48h, and seven days post-operatively, serum urea levels, renal histology, and mRNA expression levels of inflammatory and injury genes were determined to assess kidney function and damage. Additionally, matrix metalloproteinase activity in the kidney was assessed six months after IRI. Two days of fasting improved survival the first week after renal IRI in WT mice compared with AL fed mice. Short term AL fed Fibulin-4+/R mice showed improved survival and kidney function compared with AL fed WT mice, which could not be further enhanced by fasting. Both fasted WT and Fibulin-4+/R mice showed improved survival, kidney function and morphology compared with AL fed mice six months after renal IRI. Fibulin-4+/R kidneys of fasted mice showed reduced apoptosis together with increased matrix metalloprotease activity levels compared with AL fed Fibulin-4+/R mice, indicative of increased matrix remodelling. Fibulin-4+/R mice are naturally protected against the short-term, but not long-term, consequences of renal IRI. Pre-operative fasting protects against renal IRI and prevents (long-term) deterioration of kidney function and morphology in both WT and Fibulin-4+/R mice. These data suggest that pre-operative fasting may decrease renal damage in patients undergoing open abdominal aneurysm repair.

The evaluation of acute kidney injury due to ischemia by urinary neutrophil gelatinase-induced lipocalin (uNGAL) measurement in patients who underwent partial nephrectomy.

To investigate the role of urinary neutrophil gelatinase-induced lipocalin (uNGAL) measurement in the early diagnosis of acute kidney injury that may occur after intraoperative ischemia in patients undergoing partial nephrectomy (PN). This prospective study included 86 patients who underwent open laparoscopic or robotic partial nephrectomy between May 2017 and May 2019. During the surgery, whether the patients had ischemia or not, type of vascular clamping and the ischemia time were noted. The definition of acute kidney injury (AKI) was classified according to Acute Kidney Injury Network (AKIN) criteria. Urine samples were collected preoperatively and 3h after renal pedicle clamp removal and uNGAL was measured. AKI was recorded in 34 (39.5%) of 86 patients after PN. Of the 34 patients, 26 (76.4%) had level 1 and 8 (23.6%) had level 2 AKI. uNGAL levels increased significantly as an early reflection of AKI in patients who underwent intraoperative total or renal artery clamping (p = 0.024). There was no significant postoperative increase in uNGAL in the non-ischemic group (p = 0.163). uNGAL expression was detected well before serum creatinine increase. Patients with AKI after PN had higher uNGAL expression (p = 0.008) However, there was no correlation between the level of AKI and uNGAL expression (r = 0.201, p = 0.066). Ischemic acute kidney injury after nephron-sparing surgery can be detected early by uNGAL measurement. In future studies comparing outcomes of different surgical techniques on renal functions after PN, uNGAL levels may be used.

Laser speckle contrast imaging of forehead cutaneous blood flow during carotid endarterectomy as a potential non-invasive method for surrogate monitoring of cerebral perfusion.

Monitoring cerebral perfusion is important for goal-directed anesthesia. Taking advantage of the supply of the supraorbital region and Glabella from the internal carotid artery (ICA), we evaluated changes in cutaneous blood flow using laser speckle contrast imagining (LSCI) as a potential method for indirect real-time monitoring of cerebral perfusion. Nine patients (8 men, mean age 70years) underwent eversion carotid endarterectomy under local anesthesia. Cutaneous blood flow of the forehead was monitored using LSCI. During clamping of the common carotid artery (CCA), ipsilateral supraorbital region and Glabellas cutaneous blood flow dropped from 334 ± 135 to 221 ± 109 AU (p = 0.023) (AU: arbitrary flux units) and from 384 ± 151 to 276 ± 107 AU (p = 0.023), respectively, whilst the contralateral supraorbital region cutaneous blood flow remained unchanged. The supraorbital cutaneous blood flow did not change significantly following reperfusion of the external carotid artery (ECA) (221 ± 109 to 281 ± 154 AU; p = 0.175) and ICA (281 ± 154 to 310 ± 184 AU; p = 01). A comparable trend for Glabella followed ECA (276 ± 107 to 342 ± 170 AU; p = 0.404) and ICA (342 ± 170 to 352 ± 191 AU; p = 01) reperfusion. In patients undergoing carotid endarterectomy under local anesthesia, LSCI of the supraorbital and Glabella regions reflected clamping of the CCA but did not distinguish reperfusion of the ICA from that of the ECA.

Video 10 - Selective Segmental Renal Artery Clamping During Retro and Trans-Peritoneal Robotic-Assisted Laparoscopic Partial Nephrectomy for Hilar Tumours: Technique and Outcome

Video 10 - Selective Segmental Renal Artery Clamping During Retro and Trans-Peritoneal Robotic-Assisted Laparoscopic Partial Nephrectomy for Hilar Tumours: Technique and Outcome

Early Outcomes in the ROADSTER 2 Study of Transcarotid Artery Revascularization in Patients With Significant Carotid Artery Disease.

Transcarotid artery revascularization (TCAR) is comprised of carotid artery stent placement with cerebral protection via proximal carotid artery clamping and reversal of cerebral arterial flow. The aim of the present study was to evaluate the safety and efficacy of TCAR performed by a broad group of physicians with variable TCAR experience. The ROADSTER 2 study is a prospective, open label, single arm, multicenter, postapproval registry for patients undergoing TCAR. Patients considered at high risk for complications from carotid endarterectomy with symptomatic stenosis ≥50% or asymptomatic stenosis ≥80% were included. The primary end point was procedural success, which encompassed technical success plus the absence of stroke, myocardial infarction, or death within the 30-day postoperative period. Secondary end points included technical success and individual/composite rates of stroke, death, and myocardial infarction (MI). All patients underwent independent neurological assessments before the procedure, within 24 hours, and at 30 days after TCAR. An independent clinical events committee adjudicated all major adverse events. Between 2015 and 2019, 692 patients (Intent to Treat Population) were enrolled at 43 sites. Sixty cases had major protocol violations, leaving 632 patients adhering to the Food and Drug Administration-approved protocol (per-protocol population). The majority (81.2%) of operators were TCAR naïve before study initiation. Patients underwent TCAR for neurological symptoms in 26% of cases, and all patients had high-risk factors for carotid endarterectomy (anatomic-related 44%; physiological 32%; both 24%). Technical success occurred in 99.7% of all cases. The primary end point of procedural success rate in the Intent to Treat population was 96.5% (per-protocol 97.9%). The early postoperative outcomes in the Intent to Treat population included stroke in 13 patients (1.9%), death in 3 patients (0.4%), and MI in 6 patients (0.9%). The composite 30-day stroke/death rate was 2.3%, and stroke/death/MI rate was 3.2%. In the per-protocol population, there were strokes in 4 patients (0.6%), death in one patient (0.2%), and MI in 6 patients (0.9%) leading to a composite 30-day stroke/death rate of 0.8% and stroke/death/MI rate of 1.7%. TCAR results in excellent early outcomes with high technical success combined with low rates of postprocedure stroke and death. These results were achieved by a majority of operators new to this technology at the start of the trial. Adherence to the study protocol and peri-procedural antiplatelet therapy optimizes outcomes. Longer-term follow-up data are needed to confirm these early outcomes. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02536378.

Segmental artery clamping versus main renal artery clamping in nephron-sparing surgery: updated meta-analysis

ObjectivesIschemia–reperfusion injury is harmful in partial nephrectomy (PN) in renal cell carcinoma. Choosing an appropriate surgical method is important to reduce ischemia–reperfusion injury. This study aimed to compare the effect of segmental artery clamping (SAC) and main renal artery clamping (MAC) on patients who underwent PN.MethodsStudies from January 2008 to November 2019 were identified by an electronic search of English and Chinese databases, including PubMed, Excerpt Medica Database, Cochrane Library, Wanfang, VIP, and Chinese National Knowledge Internet, without language restriction. Two reviewers were involved in the trial. The effects on operation time (OT), warm ischemia time (WIT), length of hospital stay (LOS), blood transfusion rate, postoperative complication rate, Clavien classification (≥ 3), and positive surgery margin (PSM) were evaluated using Stata software. Standardized mean difference (SMD, for continuous data) and pooled odds ratios (for count data) with 95% confidence interval (CI) were used as effect indicators.ResultsThirty-two studies were included. SAC decreased the 1-week (SMD = − 0.973; 95% CI = − 1.414, − 0.532; P = 0.000), 1-month (SMD = − 0.411; 95% CI = − 0.769, − 0.053; P = 0.025), and 3-month (affected kidney: SMD = − 0.914; 95% CI = − 1.662, − 0.617; P = 0.000) percentages of postoperative changes in renal function (estimated glomerular filtration rate) between the SAC and MAC groups. Sub-group analysis showed that the SAC group had longer OT (SMD = 0.562; 95% CI = 0.252, 0.871; P = 0.000) than the MAC group. However, no differences were observed in the OT, WIT, LOS, blood transfusion rate, postoperative complication rate, Clavien classification (≥ 3), and PSM between the two groups.ConclusionsSAC is superior to MAC in terms of short-term postoperative renal function recovery. The use of SAC or MAC depends on tumor size, location, surgical modality, and surgeon’s judgments.

The role of mesenteric lymph exosomal lipid mediators following intestinal ischemia-reperfusion injury on activation of inflammation

Intestinal ischemia caused by hemorrhagic shock is known to induce systemic inflammatory responses. Previous studies have shown that mesenteric lymph (ML) plays a crucial role in gut-mediated inflammation. Lipid mediators, such as lysophosphatidylcholines (LPCs), which contain polyunsaturated fatty acids (PUFAs), are present in the postshock ML. Exosomes are also present in the ML and act as transcellular carriers of lipids; however, their role in postshock systemic inflammation has not been revealed. Here, we aimed to identify changes in lipid mediators in ML exosomes after intestinal ischemia. Male Sprague-Dawley rats underwent laparotomy, followed by ML duct cannulation. Animals were subjected to 60 minutes of intestinal ischemia by superior mesenteric artery clamping, followed by 120 minutes of reperfusion. Mesenteric lymph was obtained before and after intestinal ischemia, and exosomes were isolated from ML by ultracentrifugation. The biological activity of ML exosomes was determined using the monocyte nuclear factor κB (NF-κB) activation assay. Lipids of ML exosomes were extracted and quantified by liquid chromatography/electrospray ionization mass spectrometry. Mesenteric lymph exosome-induced NF-κB activation significantly increased after intestinal ischemia, and lipid analysis revealed a significant increase in the concentration of PUFA-containing LPCs. In addition, PUFA-containing LPCs also induced NF-κB activation. Our results suggest that biologically active lipid mediators in ML exosomes may be involved in the inflammatory response after intestinal ischemia.