Artery Vein Research Articles

Abstract 4118070: High Output Heart Failure After Leadless Pacemaker Placement In a Heart Transplant Recipient

Introduction: The advent of leadless pacemaker (LP) technology has revolutionized cardiac rhythm management by minimizing risks associated with traditional transvenous pacemakers. LP use is expected to increase as dual-chamber LP systems emerge into clinical practice. The LP requires a large-bore venous sheath (27-Fr) through a femoral vein. One risk of large bore femoral cannulation is creation of an occult arteriovenous fistula (AVF), which can cause high output heart failure (HOHF) over time. In the LEADLESS II trial, the event rate for AVF was 0.2%. HOHF as a complication of LP implant has not been previously reported. We describe the first case of HOHF in a heart transplant (HT) recipient after LP. Case Presentation: An 82-year-old male with a history of HT 26 years earlier underwent leadless pacemaker for recurrent syncope, deemed associated with conduction system disease. He had no history of cardiac allograft rejection, angiographic coronary allograft vasculopathy or left ventricular dysfunction. Six months post-implant he presented with shortness of breath and bilateral lower extremity edema. Management: Evaluation included: 1) Chest X-ray which was suggestive of pulmonary edema 2) natriuretic peptide level of 5,500 pg/ml (6-fold increase from 6 months prior) 3) echocardiogram showing EF of 69%, and 4) bilateral lower extremity Doppler ultrasound where he was found to have a large AVF between the right superficial femoral artery and superficial femoral vein. Subsequent right heart catheterization was notable for a PCWP of 18 mmHg and a cardiac output/index of 11 L/min and 5.8 L/min/m2 respectively, hence confirming HOHF. Treatment with intravenous diuretic was initiated and percutaneous stent placement to correct the AVF was performed with symptomatic relief. Conclusion: This case highlights the rare but serious complication of unrecognized AVF following leadless pacemaker implant. Given that this event occurred in a HT recipient, a more exhaustive work-up was required to rule-out expected causes of congestion. To our knowledge there is only one other case report describing AVF post-LP implant for which no intervention was performed due to absence of symptoms at 6-month follow up and HOHF was not reported. Our case emphasizes that the differential diagnosis of new onset of signs and symptoms of heart failure that develop post LP implant in general and in HT recipients specifically, should include HOHF related to an unrecognized procedural AVF.

Development of quantitative PET/MR imaging for measurements of hepatic portal vein input function: a phantom study

BackgroundAccurate pharmacokinetic modelling in PET necessitates measurements of an input function, which ideally is acquired non-invasively from image data. For hepatic pharmacokinetic modelling two input functions need to be considered, to account for the blood supply from the hepatic artery and portal vein. Image-derived measurements at the portal vein are challenging due to its small size and image artifacts caused by respiratory motion. In this work we seek to demonstrate, using phantom experiments, how a dedicated PET/MR protocol can tackle these challenges and potentially provide input function measurements of the portal vein in a clinical setup.MethodsA custom 3D printed PET/MR phantom was constructed to mimic the liver and portal vein. PET/MR acquisitions were made with emulated respiratory motion. The PET/MR imaging protocol consisted of high-resolution anatomical MR imaging of the portal vein, followed by a PET acquisition in parallel to a dedicated motion-tracking MR sequence. Motion tracking and deformation information were extracted from PET data and subsequently used in PET reconstruction to produce dynamic series of motion-free PET images. Anatomical MR images were used post PET reconstruction for partial volume correction of the input function measurements.ResultsReconstruction of dynamic PET data with motion-compensation provided nearly motion-free series of PET frame data, suitable for image derived input function measurements of the portal vein. After partial volume correction, the individual input function measurements were within a 16.1% error range from the true activity in the portal vein compartment at the time of PET acquisition.ConclusionThe proposed protocol demonstrates clinically feasible PET/MR imaging of the liver for pharmacokinetic studies with accurate quantification of the portal vein input function, including correction for respiratory motion and partial volume effects.

Imaging of the Inferior Mesenteric Vasculature.

The inferior mesenteric artery (IMA) and inferior mesenteric vein (IMV) supply and drain blood from the distal colon and rectum, respectively. Routinely imaged at cross-sectional imaging of the abdomen and pelvis, these vessels play a vital role in gastrointestinal tract health but may be neglected due to their diminutive caliber relative to other mesenteric vessels and potential lack of inclusion in routine search patterns. The authors describe and illustrate normal and abnormal appearances of the IMA and IMV and findings that are diagnostic of primary vascular abnormalities or can offer diagnostic clues. After the embryologic features, normal anatomy, and anatomic variants of the IMA and IMV are reviewed, various manifestations of IMA and IMV abnormalities, such as aneurysm and pseudoaneurysm, stenosis, occlusion, dissection, hemorrhage, arteriovenous malformations and fistulas, tumoral invasion, vasculitis, and perivascular lymphatic dilatation, are explored with use of case examples. The role of the IMA and IMV as collateral vasculature, including the clinical scenarios of superior mesenteric arterial occlusion, aortic endoleak, and portosystemic venous shunt, are discussed. Finally, diagnostic clues that the inferior mesenteric vessels and adjacent soft tissues can provide, including mesenteric venous gas, compression or displacement from bowel volvulus or internal hernias, lymphadenopathy, and venous flow artifacts, are highlighted. The authors provide a comprehensive reference for radiologists who evaluate the IMA and IMV on cross-sectional images and shine a spotlight on these neglected but important vessels. ©RSNA, 2024 Supplemental material is available for this article.

The course of the phrenic nerve in the neck region and its relationship with adjacent anatomical structures in the thoracic inlet.

This study aims to reveal the relationship of the phrenic nerve (PhN) with its neighboring structures in the lower neck region more comprehensively than previous studies and to minimize nerve damage by enabling invasive procedures in this region to be performed with high accuracy. Forty-one heminecks were evaluated. The relationship between the PhN and the anterior scalene muscle (ASM), internal thoracic artery (ITA), branches of subclavian artery (SA) and subclavian vein (SV) was examined. It was observed that the PhN was located medial to the ASM in all cases. The distances were higher in male cadavers. The PhN was found to enter the thorax lateral to the ITA in 15/41 and medial to it in 25/41 sides. In 17/41 cases, the closest SA branch to the PhN was the thyrocervical trunk (TT) and in 24 cases the ITA. The PhN was located behind the SV in 38 cases and in front of it in 2 cases.The accessory PhN was found in 4/41 sides. There was no significant difference in morphometric findings between genders (p > 0.05). However, significant differences were observed between the parameters (p < 0.05). The anatomy and variations of the PhN are of great importance in surgical interventions and invasive procedures in the neck region. The study provides important information to reduce the risk of damage to the PhN in surgical procedures. In addition, knowledge of the anatomical variations of the nerve may contribute to more successful results in nerve grafting and other surgical applications.

Great Saphenous Vein Arterialization in Patients with Severe Chronic Limb Threatening Ischemia: A Last Resort for Limb Salvage

ObjectiveIn one-fifth of patients with chronic limb-threatening ischemia there are no revascularisation options. In those cases, venous arterialisation could be a last resort for limb salvage. This study examines the clinical outcome of 17 patients, with non-healing wounds (Fontaine 4), who underwent Great Saphenous Vein (GSV) arterialisation leaving the distal saphenous side branches open and avoiding incisions in the lower leg and foot. MethodsIn this retrospective study all the patients who underwent GSV arterialisation between 1 January 2020 and 1 October 2023 were included. During the procedure, a small incision was made in the groin to identify the GSV and SFA. The GSV was detached from the deep venous system, the upper leg side branches were ligated, and the side branches distal to the knee joint were left open to create a pressure drop. Valvulotomy of the GSV down to the foot was performed in all patients. This approach does not necessitate the use of grafts or stents so that a serious infected foot can also be treated. For this study we have analysed the Limb salvage, wound healing, and mobility after treatment and observed pre and postoperative skin oxygenation over a one-year period. ResultsThis intervention resulted in a limb salvage rate of 46% and a secondary patency of 88% after one year in cases where amputation would have otherwise been necessary. Pre- and postoperative TcPO2 measurements indicated a gradual but consistent increase in skin oxygenation in 71% of the patients with a GSV larger than 3mm, underscoring the importance of future patient selection. All patients who successfully received arterialisation showed complete wound healing and improved mobility. ConclusionThis study introduced a promising approach to venous arterialisation in patients with severe CLTI who have no other treatment options, potentially impacting disease burden and quality of life significantly.

Endovascular embolization of a congenital inferior phrenic artery-to-pulmonary arteriovenous malformation: a rare case report

BackgroundPulmonary arteriovenous malformation (PAVM) is abnormal arteriovenous shunts between pulmonary artery (PA) and pulmonary vein, and rarely has congenital direct communications with systemic arteries.Case PresentationA 33-year-old male presented to our hospital with intermittent bloody sputum with no evidence of pulmonary infection, trauma or surgery. Chest computed tomography angiography (CTA) indicated the congenital inferior phrenic artery (IPA)-to-PAVM surrounded by diffuse alveolar hemorrhage located in the lower lobe of right lung. Both the afferent PA and IPA were successfully embolized with coils. Recurrent hemoptysis did not occur during one-year follow up.ConclusionsThe congenital communication between IPA and PAVM is rare, and the abnormal direct shunt would induce hemodynamically unstable condition within PAVM. Endovascular embolization of the afferent PA and IPA is a safe and effective method for this abnormal congenital shunt in lung.

Portal Vein Arterialization as a Lifesaving Strategy for Hepatic Artery Injury in Robotic Hepatectomy.

Roboticvascular resection and reconstruction is a challenging procedure. Portal vein arterialization (PVA) can offer an efficient solution in those cases in which the hepaticartery cannot be reconstructed.1.Can J Surg 64:e173-e182;2.The Paul Brousse Hospital Experience. HPB (Oxford) 16:723-738;3.J Am Coll Surg 207:e1-6; PVA increases oxygen supply to theremaining partoftheliver, promotesliver regeneration, and prevents liver failure.Majlesara A, Golriz M, Ramouz A, et al. Portal vein arterialization as a salvage method in advanced hepatopancreatobiliary surgery. Br J Surg. 2024;111. In this multimedia article, we describea patient who was treated with PVA for a robotic hepatic arteryinjury during robotic left-liver-first anterior radical modular orthotopic right hemihepatectomy (Rob-Larmorth).5.Ann Surg Oncol 31:5636-5637 METHODS: A 52-year-old male patient was admitted with epigastricpain. Further imaging showed intrahepaticcholangiocarcinoma involving the root of the right anterior branch of the portal vein. Following multidisciplinary consultation, surgical resection was recommended as the primary approach. The robotic technique was chosen in this operation, with preoperative anticipation of needing Rob-Larmorth. Unfortunately, the left hepatic artery sustained unintended damage during skeletonization of the duodenal ligaments. Anastomosis could not be performed due to severe damage to the distal end intima. We utilized PVA technology to anastomose the hepatic artery to the portal vein. Finally, Rob-Larmorth and PVA were successfully performed. The surgery took 490min and the estimated blood loss was approximately 300mL. No blood transfusion was performed.Postoperatively, the patient recovered smoothly without liver failure, although percutaneous drainage was required due to bile leakage. Pathological examination revealed moderately to poorly differentiated bile duct cell carcinoma (T2N0M0, stage II). No recurrence was observed during the 12-month follow-up. PVA can be an effective solution when no other revascularization options are available.Implementing PVA as a bridging procedure increases oxygen delivery to the remnant liver, facilitating regeneration and reducing the risk of liver failure. The development of arterial collaterals is a significant concern for individuals undergoing PVA. Complications reported after PVA include early shunt thrombosis, portal hypertension, and a notable 90-day mortality rate.1.Can J Surg 64:e173-e182 However, Majlesara and colleagues found no evidence of postoperative liver damage associated with PVA. They also reported low morbidity rates and no associated mortality for both one- and two-stage embolization of the arterioportal shunt.Majlesara A, Golriz M, Ramouz A, et al. Portal vein arterialization as a salvage method in advanced hepatopancreatobiliary surgery. Br J Surg. 2024;111. PVA can offer an effective solution when hepatic artery reconstruction is not feasible.

Percutaneous Deep Venous Arterialization by Balloon Angioplasty without Stent Implantation for Patients with Chronic Limb-Threatening Ischemia Undergoing Hemodialysis: A Retrospective Cohort, Single-Center, Single-Arm Study.

This retrospective, single-center study aimed to determine the efficacy of percutaneous deep venous arterialization in patients on hemodialysis with chronic limb-threatening ischemia. Twenty-one consecutive limbs on hemodialysis with chronic limb-threatening ischemia were treated with percutaneous deep venous arterialization using balloon angioplasty following a failed pedal arterial reconstruction between May 2021 and June 2022. An arteriovenous fistula near the ankle joint was created to ensure sufficient venous flow reversal to the pedal veins. In case of occlusion of the tibial artery, a guidewire was advanced (subintimal) to the ankle joint vicinity was technically important. The primary outcome measures were the 6-month complete wound healing and freedom from major amputation rates; the secondary outcome measure was the 6-month amputation-free survival. Occlusion of all pedal arteries was observed in 17 limbs (81.0%). Arteriovenous fistulas were predominantly created at the distal portions of the posterior tibial artery and vein in 18 limbs (85.7%). No extravasation at the fistulas was observed. Re-intervention was required in 16 limbs (76.2%) due to tibial artery or deep vein occlusion. The 6-month complete wound healing rate was 42.9% (nine limbs), with a median healing time of 85 days (interquartile range: 58-151 days). The 6-month freedom from major amputation and amputation-free survival rates were 90.5% (19 limbs) and 61.9% (13 limbs), respectively. Balloon angioplasty without stent implantation for percutaneous deep venous arterialization is promising for improving the complete wound healing and amputation-free survival rates after pedal artery reconstruction failure. Level 3b, retrospective cohort study.

Effect of a novel cannulation device for vascular access on AVF maturation in a goat carotid-jugular fistula model.

The Ark is a 3-D printed titanium device designed to be implanted around the draining vein of an arteriovenous fistula (AVF) to facilitate vascular access. The purpose of this study was to assess AVF maturation after Ark implantation in a large animal model. End-to-side AVFs were created between the carotid artery and jugular vein in nine pygmy goats that included three control (AVF only) and six experimental (AVF and Ark device) animals. For experimental animals, an Ark device was implanted approximately 10 cm downstream of the anastomosis at the time of AVF creation. Postoperative ultrasounds and cannulations of the jugular vein fistula were performed over 12 months. At the conclusion of the study, the AVF was ligated and Ark devices along with a segment of the arterialized vein and surrounding tissues were explanted for gross and histological assessment. The control and experimental Ark groups exhibited increased dilation and flow as well as diminished depth underscoring the parallel developments in vascular attributes and AVF maturation between the two groups. Gross pathology, histology, and micro-CT imaging revealed intact endothelium, mature tissue integration throughout the porous Ark device, and no underlying stenosis. No adverse events such as foreign body reaction, skin or vessel erosion were identified. The study showed maturation without stenosis of the fistula in all animals. This study confirmed that the Ark device functions as a scaffold around the access vein, allows fistula maturation, and can be consistently cannulated without infiltrations over a 12-month period in a large animal model.

TCT-706 One-Year Pooled Outcomes of Transcatheter Arterialization of the Deep Veins From the PROMISE I, II, and UK Studies

TCT-706 One-Year Pooled Outcomes of Transcatheter Arterialization of the Deep Veins From the PROMISE I, II, and UK Studies

Spatial Transcriptomic Profiling of Human Saphenous Vein Exposed to Ex Vivo Arterial Haemodynamics-Implications for Coronary Artery Bypass Graft Patency and Vein Graft Disease.

Vein graft disease is the process by which saphenous vein grafts, utilised for revascularisation during coronary artery bypass graft surgery, undergo an inflammation-driven intimal hyperplasia and accelerated atherosclerosis process in subsequent years after implantation. The role of the arterial circulation, particularly the haemodynamic properties' impact on graft patency, have been investigated but have not to date been explored in depth at the transcriptomic level. We have undertaken the first-in-man spatial transcriptomic analysis of the long saphenous vein in response to ex vivo acute arterial haemodynamic stimulation, utilising a combination of a custom 3D-printed perfusion bioreactor and the 10X Genomics Visium Spatial Gene Expression technology. We identify a total of 413 significant genes (372 upregulated and 41 downregulated) differentially expressed in response to arterial haemodynamic conditions. These genes were associated with pathways including NFkB, TNF, MAPK, and PI3K/Akt, among others. These are established pathways involved in the initiation of an early pro-inflammatory response, leukocyte activation and adhesion signalling, tissue remodelling, and cellular differentiation. Utilising unsupervised clustering analysis, we have been able to classify subsets of the expression based on cell type and with spatial resolution. These findings allow for further characterisation of the early saphenous vein graft transcriptional landscape during the earliest stage of implantation that contributes to vein graft disease, in particular validation of pathways and druggable targets that could contribute towards the therapeutic inhibition of processes underpinning vein graft disease.

Accurate repair of oral and maxillofacial soft tissue defects with ulnar artery flap

To investigate the characteristics of the clinical application of ulnar artery flap in the repair of oral and maxillofacial soft tissue defects. The clinical data of 12 patients with oral and maxillofacial defects repaired with ulnar artery flap between June 2021 and July 2023 was retrospectively analyzed. Among them, 11 cases were male and 1 case was female; their ages ranged from 28 to 76 years, with a mean age of 54.8 years. The lesions were located in the lateral margin of the tongue in 3 cases, the root of the tongue in 2 cases, the base of the tongue in 4 cases, and the buccal region, upper gingiva, and lower lip in 1 case each. The pathological types were squamous cell carcinoma in 11 cases and adenoid cystic carcinoma in 1 case; according to the TNM staging of the International Union Against Cancer (UICC), there were 5 cases of T 3N 0M 0, 2 cases of T 3N 1M 0, 1 case of T 4aN 0M 0, 1 case of T 4aN 1M 0, 1 case of T 4aN 2bM 0, and 2 cases of T 4aN 2cM 0. After complete resection of the lesion, the defect ranged from 6 cm×3 cm to 8 cm×5 cm. Preoperatively, colour Doppler ultrasound was used to detect the non-dominant forearm, measure the thickness of the subcutaneous fat in the donor area, confirm and mark the ulnar artery and reflux vein, and measure the diameter of the vessels, flow velocity, and the perforator position; intraoperatively, the flap was designed, prepared, anastomosed, and positioned according to the corresponding data. The vessels were all anastommosed with one artery and two veins to form a super-reflux. After complete hemostasis, the defects were repaired with sliding flap (2 cases), direct suture (4 cases), biomembrane (2 cases), or razor thin skin graft (4 cases). No vascular crisis occurred after operation, and all the flaps survived in 12 cases. Wounds in the donor site healed by first intention in 10 cases and by second intention in 2 cases. Wounds in the recipient site healed by first intention in all cases. All 12 patients were followed up 5-18 months, with an average of 11.4 months. The colour and texture of the flap were normal. The function of hand and upper limb was evaluated according to the trial standard of upper limb function assessment of the Chinese Society of Hand Surgery of the Chinese Medical Association, and the score was 65-81 (mean, 71.3), and achieved excellent in 1 case and good in 11 cases. The score of Oral Health Impact Scale (OHIP) was 9-18, with an average of 14.2, and the oral function was satisfactory. During the follow-up, 1 case had local recurrence and underwent extended resection again, while the other patients had no recurrence or metastasis. For moderate soft tissue defects with complex oral and maxillofacial function, ulnar artery flap repair is effective.

Influences of V-A Mode Assisted ECMO Combined with Intra-Aortic Balloon Counterpulsation on Disease Outcome and Troponin Level in Patients with Acute Fulminant Myocarditis

Introduction: The acute fulminant myocarditis (AFM) is a special type of myocarditis, characterized by rapid onset, progression with abnormal hemodynamics causing high mortality. The combination of extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon counterpulsation (IABP) in these cases have improved the acute phase attacks resulting in increased survival of the effected individuals. To observe the effect of vein-artery (V-A) mode assisted ECMO combined with IABP on the disease outcomes and troponin level in patients with acute fulminant myocarditis (AFM). Methods: A total of 45 patients with AFM were admitted to our hospital from January 2016 to December 2021, they were divided into group A (21 patients, receiving traditional treatment) and group B (24 patients, receiving V-A mode assisted ECMO and IABP based on traditional treatment) according to the treatment plan. The hypersensitive troponin (hs-cTnI), B-type natriuretic peptide (BNP), arterial blood gas analysis index, multiple organ dysfunction score (MODS), simplified acute physiology score II (SAPS II), cardiac ultrasound index, and disease outcomes were compared between the two groups. Results: After treatment, the hs-cTnI, BNP, blood lactic acid, MODS score and SAPS score in both groups were lower than before treatment (p &lt; 0.05), the arterial oxygen saturation (SaO2), left ventricular ejection fraction (LVEF) and cardiac index (CI) was higher than before treatment (p &lt; 0.05), the hs-cTnI, BNP, blood lactic acid, MODS score and SAPS Ⅱ score in group B were lower than group A (p &lt; 0.05), SaO2, LVEF and CI was higher than group A (p &lt; 0.05). The in-hospital mortality of group B (9.52%, 2/21) was lower than group A (45.83%, 11/24) (χ2 = 7.188, p = 0.007). Among the recovered discharged patients, the length of stay in group B (19 patients, 14.42 ± 4.59 days) was shorter than group A (13 patients, 18.34 ± 5.72 days) (t = 2.147, p = 0.040). Conclusions: V-A mode assisted ECMO combined with IABP can improve the condition and arterial blood gas analysis index and cardiac function of AFM patients, alleviate myocardial injury, reduce mortality in the hospital, and shorten the hospitalization time of the recovered patients.

Use of ultrasound for vascular access during cardiac catheterisation in children with congenital heart disease: a Swiss multicentre cohort study.

Our study aimed to assess the first-attempt success rate of ultrasound (US) and anatomical landmark (ALM) guidance for vascular cannulation in children with congenital heart disease in Switzerland. A prospective observational multicentre study was conducted from January 2022 to January 2023 in three university hospitals in Switzerland. We included patients with congenital heart disease aged 0 to 18 years who were scheduled for elective cardiac catheterisation. Periprocedural data were collected anonymously. The choice of vessel and guidance technique were at the operator's discretion. 177 arterial and 240 venous cannulations in 253 patients were analysed. The median age and weight were 4.4 years (interquartile range [IQR] 1.2-8.8) and 15 kg (IQR 8-27), respectively. Nearly all operators, 97.5%, were deemed experienced. The femoral artery and femoral vein were the most preferred vessels. US guidance was used in 62% of procedures, predominantly within populations who were younger, smaller and of lower weight.The success rate at the first attempt was notably higher with US guidance for arterial cannulation (US: 80%, ALM: 37%, p <0.001) and venous cannulation (US: 78% vs ALM: 47%, p <0.001). Overall success rates for venous and arterial cannulation were comparable between ultrasound and anatomical landmark guidance. A total of 45 complications (10.5%) occurred, with immediate uncomplicated haematoma being the most frequent. US guidance is preferred for the localisation and cannulation of vessels during cardiac catheterisation within paediatric cardiology departments in Switzerland. Given its high success rate for first-attempt cannulation, US warrants additional research to evaluate its potential in reducing complications.

Abstract P173: Pivotal Role for the Kinin B1R in CB1 Receptor Mediated Neuroinflammation and Pressor Response

The cannabinoid receptors CB1R and CB2R are involved in blood pressure (BP) regulation and CB1R is implicated in the incidence of hypertension. CB1R is highly expressed in the brain but both receptors are also expressed in the heart. Prior research has demonstrated that CB1R mediates significant cardiovascular responses, including elevated BP, heightened plasma norepinephrine levels, and increased sympathetic nerve activity. Furthermore, the activation of the kinin B1 receptor (B1R) mediates similar effects when studied independently. However, the role of B1R in CB1R-mediated BP regulation and the associated signaling mechanisms remain unknown. In this study, we tested the hypothesis that B1R plays a pivotal role in CB1R-mediated pressor response, oxidative stress and neuroinflammation. To test this, we used both in vivo mouse models and in vitro primary hypothalamic neurons. Male C57BL/6NJ wild-type (WT) and B1R knockout mice (B1RKO) underwent surgical carotid artery and jugular vein catheterization to measure BP in conscious state. Following stabilization of BP for at least 90 minutes, the CB1R agonist WIN55,212-2 (300 ug/kg; i.v., WIN) or its vehicle was administered, and recordings continued for 45 minutes. WIN increased BP in WT mice (25±7 mmHg vs baseline), but this effect was blunted in B1RKO mice (n=3, p&lt;0.05). Moreover, administration of WIN led to an augmentation of CB1R expression in the paraventricular nucleus of WT mice, but not in B1RKO mice, thereby indicating the involvement of B1R in CB1R signaling (p&lt;0.05, n=3 mice/group). WT, but not B1RKO, mice treated with WIN displayed a significant increase in oxidative stress levels (p&lt;0.05, n=3 mice/group), as indicated by dihydroethidium staining. To further confirm the role of B1R blockade on CB1R signaling, we cultured primary hypothalamic neurons, as neurons express the highest levels of CB1R in the brain. Neurons were stimulated with WIN (1 uM) both with and without a B1R selective antagonist (SSR240612, 10uM). The results indicated that WIN incubation for 24 hours increased CB1R expression, inflammation, and oxidative stress compared to vehicle treated, and these responses were abrogated by prior B1R blockade (p&lt;0.05, n=5/group), consistent with the in vivo observations. These data provide novel evidence that B1R is implicated in CB1R-mediated proinflammatory responses and serves as a potential therapeutic target to reduce CB1R induced effects.

343.5: Hypothermic oxygenated machine perfusion of the liver via hepatic artery and portal vein reduces biliary complications.

343.5: Hypothermic oxygenated machine perfusion of the liver via hepatic artery and portal vein reduces biliary complications.

802. TECHNICAL DETAILS: FREE JEJUNAL GRAFT AND REVERSE SAPHENOUS VEIN GRAFT FOR RECONSTRUCTION AFTER TOTAL PHARYNGO-LARYNGECTOMY AND PROXIMAL ESOPHAGECTOMY

Abstract Background We would like to show our tips for free jejunal graft and vascular reconstruction after pharyngo-laryngectomy and proximal esophagectomy. Methods 65 years-old man with history of hypopharynx squamous cell carcinoma cT3 cN0 cM0 who underwent radical Qt/Rt with initially complete response. After 2 years follow-up, he presented dysphagia and recurrence of squamous cell carcinoma proven by histology. Upper endoscopy shows cervical esophageal stenosis due to tumor infiltration. Rescue surgery was decided after systemic dissemination was ruled out with PET-CT. Results Pharyngo-laryngectomy, total thyroidectomy and proximal esophagectomy was performed. Free margin tumor was confirmed by frozen section. Jejunal segment with adequate vascular supply is selected, preferable with a single artery and vein. Peristaltic direction of the jejunum is marked to avoid mistakes during graft transposition. Division of mesenteric branches to prevent postoperative bleeding. Before jejunal section we recommend administration of hyoscine butilbromide 20 mg iv to avoid jejunal spams. Measuring the length graft needed before dividing the jejunum to avoid redundant or short graft is recommended. We must carefully isolate the pedicle avoiding damaging blood supply. To reduce time of ischemia, jejunal graft pedicle should not be ligated until cervical dissection is completed and we have ruled out if venous graft may be needed. After cervical artery and vein dissection, we ensure adequate blood flow and heparinize vessels before clipping. When dividing the pedicle, artery should be divided before the vein to avoid venous congestion, posteriorly we must heparinize the vessels. Povidone-iodine intraluminal washing is recommended. Jejuno-jejunal anastomosis for GI tract restoration. GI reconstruction first is recommended to avoid unnecessary traction on the vascular anastomosis. After ensuring adequate direction of the jejunal graft jejuno-esophageal anastomosis is performed with interrupted suture. Pharyngo-jejunal anastomosis is performed with barbed 3-0 running suture for anterior and posterior layer. Methylene blue test is performed for check the anastomosis. Vascular reconstruction technique depends on the vascular anatomical variations and availability. In this case, superior thyroid artery and sublingual vein were available. Saphenous vein graft might be needed, this graft must be used in reverse way to avoid the vein valves and length must be adjusted. Venous anastomosis should be performed before than arterial reconstruction after heparinize solution in both vessels to avoid thrombosis. Conclusion Free jejunal graft is a highly complex procedure that must be extremely coordinated and protocolized to avoid longer time of ischemia and risk of thrombosis that might compromise the graft viability. https://1drv.ms/v/s!AmFrct07P6MP1Fbyh_7Ce_OK5bB8?e=OMSjsK

Secondary Conduits in Coronary Artery Bypass Grafting Surgery

BackgroundRecent evidence has suggested use of the right internal mammary artery (RIMA) is associated with worse clinical outcomes in patients undergoing coronary artery bypass grafting (CABG) surgery. Therefore, we compared the clinical consequences of secondary conduit selection (RIMA vs radial artery vs saphenous vein) after CABG. MethodsA post-hoc analysis of the CABG Off or On Pump Revascularization Study, involving 3913 patients from 79 centers in 19 countries who underwent CABG surgery and received arterial grafting with at least 2 grafts. Outcomes of interest were all-cause mortality, myocardial infarction, stroke, and revascularization. ResultsA total of 3913 patients received veins (3210; 68%), radial arteries (549; 12%), or RIMAs (154; 3%) to supplement left internal mammary artery to left anterior descending artery grafts. The risk of all-cause mortality was reduced in patients who received secondary radial arteries compared with veins (weighted hazard ratio [HR], 0.79; 95% CI, 0.64-0.98) and increased in patients who received RIMA compared with veins (weighted HR, 1.37; 95% CI, 1.13-1.68) after 4.8 years of follow-up. Multiple and single arterial grafting had a similar mortality risk (weighted HR, 0.87; 95% CI, 0.73-1.03). ConclusionsSupplementing left internal mammary artery to left anterior descending artery grafting using radial arteries led to better clinical outcomes than veins, and too few RIMA were available to draw definitive conclusions. A randomized trial is needed to clarify the role of the RIMA in multiple arterial grafting CABG surgery.

Unraveling the Mystery: How High Density Lipoprotein ‘Good’ Cholesterol Goes ‘Bad’?

Background: In recent years, research has highlighted the importance of Lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1) in the progression of atherosclerosis, particularly its interaction with high-density lipoprotein (HDL). Our study aimed to explore the role of dysfunctional High-Density Lipoprotein (HDL) in binding to Lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1) among patients with Coronary Artery Disease (CAD) and its implications for the advancement of atherosclerosis. Methods: We enrolled twenty-one patients who underwent multivessel CABG using internal mammary artery (IMA), radial artery (RA), and saphenous vein (SV) grafts between November 2019 and April 2020. Using CD31 to identify endothelial cells, we evaluated LOX-1 expression in all cultured cells. Results: Our study comprised 21 patients, including 17 (80.9%) males and 4 (19.04%) females. We observed a significant positive correlation between HDL and LOX-1+ expression in specimens extracted from all types of grafts (SV, r=0.60; RA, r=0.48; IMA, r=0.53). Approximately 28% of the variation in LOX-1+ expression for IMA (F=7.03; p

Japanese expert consensus on the standardization of robot-assisted pelvic lymph node dissection in urological surgery: Extent of pelvic lymph node and surgical technique.

Pelvic lymph node dissection (PLND) is important for accurate staging and prognosis of prostate and/or bladder cancer. Several guidelines recommend extended PLND for patients with these cancers. However, the therapeutic benefits of extended PLND are unclear. One major reason is that the extent of PLND is not clearly defined. Thus, the working group for standardization of robot-assisted PLND, including nine experienced urologists for PLND in Japan, was launched in January 2023 by the Japanese Society of Endourology and Robotics. This study summarized the discussions to define the individual extent of PLND in urological surgery in a consensus meeting among these experienced urologists. The consensus meeting determined the extent of PLND based on arteries (veins) and anatomical membrane structures rather than a vague concept or approach toward PLND. This concept is expected to allow surgeons to implement the same extent of PLND. Finally, after a total of 10 online web conferences were held, we determined the extent of PLND for the obturator lymph node (LN) area, the internal iliac LN area, the external and common iliac LN area, and the presacral LN area according to the above rules. The extent of PLND suggested here currently does not have a clear therapeutic rationale. Therefore, the extent of our proposed PLND is by no means mandatory. We hope our definition of the extent of PLND will be supported by further evidence of therapeutic benefits for urologic cancers.