Autogenous Vein Grafts Research Articles

Staged treatment with arterial reconstruction and flap transplantation for ischemic mangled extremity: An observational study.

Patients with traumatic ischemic mangled extremities first undergo arterial reconstruction using autogenous vein grafts, followed by flap transplantation as a staged treatment for soft tissue reconstruction. This study aimed to report the outcomes of such a staged treatment. Thirteen patients underwent arterial reconstruction between February 2015 and April 2017 due to damage to the major blood vessels by the traumatic mangled extremities. Of them, 6 patients (5 males and 1 female with a mean age of 51 years, age range: 36-60 years) who underwent soft tissue reconstruction due to necrosis were retrospectively analyzed. The average Mangled Extremity Severity Score was 7.2 (range, 6-8). Injuries were found in the lower leg (4 cases), foot (1 case), and wrist and hand (1 case). Arterial reconstruction was performed using autologous venous grafts. The reconstructed arteries included the posterior tibial artery (3 cases), anterior tibial artery (1 case), dorsalis pedis artery (1 case), and radial artery (1 case). The blood circulation status of the reconstructed blood vessels was assessed using computed tomography angiography at an average of 5 weeks (range, 4-6 weeks) after arterial reconstruction. For some necrotic soft tissues, debridement and flap transplantation were performed an average of 7 weeks (range, 6-8 weeks) after arterial reconstruction. Soft tissue reconstruction was performed with an anterolateral thigh free flap in 4 cases, a local flap in 1 case, and a muscle flap in 1 case. In 5 out of 6 cases, blood circulation was maintained in the reconstructed blood vessels, resulting in the salvaging of the extremities. All the patients who underwent flap surgery survived. Notably, there were no special complications during a follow-up visit conducted at an average of 19 months post-reconstruction. To treat an ischemic mangled extremity, the limbs should first be salvaged with arterial reconstruction, followed by subsequent appropriate flap surgery when soft tissue necrosis occurs at the mangled site as a staged treatment.

Volar wrist ganglion associated with radial artery atherosclerosis: A case report.

There have been no reports of volar wrist ganglions being associated with atherosclerosis of the radial artery. Good results were obtained with radial artery reconstruction through ganglion excision and autogenous vein grafting. Hence, we report a previously unreported case, along with a review of the literature. A 58-year-old female presented with the chief complaint of a mass on the volo-radial side of her right wrist. The patient complained of a tingling sensation in the thumb, index, and extensor zones that worsened when pressing the mass. Sonography revealed a well-defined, anechoic cystic lesion adjacent to the radial artery. Exploration was performed using a zig-zag incision on the mass. The superficial radial nerve (SRN), which innervates the thumb, was distorted by the mass and the nerve dissected from the mass. However, the artery and ganglion cysts were not separated completely in a part where hardening of the artery wall progressed as a result of degenerative changes, showing multiple small, hard, and yellowish masses. We resected the radial artery (approximately 1.5 cm) along with the ganglion and sent it for histological examination. The radial artery was then reconstructed using an autogenous venous graft. At the 34-month follow-up, the patient was asymptomatic. Radial artery patency was normal without recurrence of the ganglion cyst. In patients with risk factors for radial artery atherosclerosis, a more careful diagnosis is required for the surgical treatment of the volar wrist ganglion. In addition, if the ganglion and radial artery are not completely dissected, excision of the radial artery and subsequent reconstruction of the radial artery using an autogenous vein may be a good surgical strategy.

Peripheral nerve defects repaired with autogenous vein grafts filled with platelet-rich plasma and active nerve microtissues and evaluated by novel multimodal ultrasound techniques

BackgroundDeveloping biocompatible nerve conduits that accelerate peripheral nerve regeneration, lengthening and functional recovery remains a challenge. The combined application of nerve microtissues and platelet-rich plasma (PRP) provides abundant Schwann cells (SCs) and various natural growth factors and can compensate for the deficiency of SCs in the nerve bridge, as well as the limitations of applying a single type of growth factor. Multimodal ultrasound evaluation can provide additional information on the stiffness and microvascular flow perfusion of the tissue. This study was designed to investigate the effectiveness of a novel tissue-engineered nerve graft composed of an autogenous vein, nerve microtissues and PRP in reconstructing a 12-mm tibial nerve defect and to explore the value of multimodal ultrasound techniques in evaluating the prognosis of nerve repair.MethodsIn vitro, nerve microtissue activity was first investigated, and the effects on SC proliferation, migration, factor secretion, and axonal regeneration of dorsal root ganglia (DRG) were evaluated by coculture with nerve microtissues and PRP. In vivo, seventy-five rabbits were equally and randomly divided into Hollow, PRP, Micro-T (Microtissues), Micro-T + PRP and Autograft groups. By analysing the neurological function, electrophysiological recovery, and the comparative results of multimodal ultrasound and histological evaluation, we investigated the effect of these new nerve grafts in repairing tibial nerve defects.ResultsOur results showed that the combined application of nerve microtissues and PRP could significantly promote the proliferation, secretion and migration of SCs and the regeneration of axons in the early stage. The Micro-T + PRP group and Autograft groups exhibited the best nerve repair 12 weeks postoperatively. In addition, the changes in target tissue stiffness and microvascular perfusion on multimodal ultrasound (shear wave elastography; contrast-enhanced ultrasonography; Angio PlaneWave UltrasenSitive, AngioPLUS) were significantly correlated with the histological results, such as collagen area percentage and VEGF expression, respectively.ConclusionOur novel tissue-engineered nerve graft shows excellent efficacy in repairing 12-mm defects of the tibial nerve in rabbits. Moreover, multimodal ultrasound may provide a clinical reference for prognosis by quantitatively evaluating the stiffness and microvescular flow of nerve grafts and targeted muscles.

Contemporary Outcomes of Open Femoropopliteal Bypass by Autogenous Vein Graft in Infra-inguinal Arterial Occlusive Disease

Although the majority of patients presenting with symptomatic peripheral arterial disease (PAD) are treated with the endovascular first approach, a significant number of these patients still require open bypass because of the extent of atherosclerotic burden or failure of the endovascular therapy. However, data available on the outcomes of femoropoliteal bypass in the contemporary era of PAD management is scarce. In this study, we evaluate realworld mid-term outcomes of femoropopliteal bypass for PAD. We identified all patients who underwent open femoropopliteal revascularization with autogenous vein conduits for PAD at one institution between January 2012 and December 2017. Main endpoints included primary patency, amputation-free survival, overall survival, and limb salvage at 2 years. Outcomes were defined as per the Society for Vascular Surgery standards. Descriptive statistics were performed using univariable analyses including the mean and standard deviation for continuous variables and frequency and percentage for categorical variables. Event-free survival rates were estimated using Kaplan-Meier methods. There were 129 patients who received autogenous vein grafts. Median follow-up was 19months (interquartile rangeIQR 11-26). Patients were predominantly male (59.7%), white (72.9%) with a mean age of 65±11years. The indications for surgery were disabling claudication in 36.4% of patients (n=47) and chronic limb threatening ischemia (CLTI) in 63.6% (n=82). Most patients had Trans-Atlantic Inter-Society Consensus C or D lesions (n=81, 62.8%). Seventeen cases (16.3%) were redoing bypasses. Arm veins and spliced vein conduits were used in 12% and 7%, respectively. In 66% of procedures, the distal anastomosis was below the knee. Primary patency estimates at 6months, 1year and 2years were 81.3%, 68.6% and 59.2%, respectively. Amputation-free survival rates were 93.4%, 88% and 82.1% at 6months, 1year and 2years, respectively. Limb salvage rates among patients with CLTI were 93.4%, 90.4% and 87.2% at 6months, 1year and 2years, respectively. Overall survival was 97.5%, 92.1% and 87.8% at 6months, 1year and 2years, respectively. In this contemporary cohort of patients, femoropopliteal bypass showed lower patency than previously described. The fact that bypass surgery is performed on sicker patients with more extensive disease in the endovascular era might explain this discrepancy. However, our results demonstrated satisfactory patency and limb salvage rates and suggest that vein should always be used if available.

Chronic Limb Ischemia due to Thrombosis of an Aneurysmal Degeneration of the Autogenous Vein Graft: A Case Report.

Nonanastomotic aneurysmal degeneration of a great saphenous vein graft is an unusual condition, despite the common use of this conduit in arterial reconstructions. Vein grafts are at risk of degenerative changes, but the real cause remains unknown. Postoperative graft surveillance with duplex ultrasound scanning is important for maintaining patency of the venous graft. We present a rare case of chronic limb ischemia due to partial thrombosis of an aneurysm of the great saphenous vein graft.

Comparison of autogenous basilic vein, polytetrafluoroethylene and polycarbonate grafts for haemodialysis access

This study aims to present data obtained by comparing the results of three different kinds of arterio-venous fistula (AVF) in hemodialysis patients. One hundred twenty (120) patients were operated with autogenous brachiobasilic (BBF) AVF, upper arm polytetrafluoroethylene (PTFE) or polycarbonate-urethane (PCU) graft AVF in our centre between January 2015 and January 2018. They were enrolled for a retrospective study into three groups; BBF Group (n=54), PTFE Graft Group (n=36), PCU Graft Group (n=30). Their data was analyzed, primary and secondary patency rates, complications and cannulation time were calculated. Primary patency rates of the 1st, 2nd and 3rd years were recorded to be respectively 81.4%, 72.2% and 59.2% in the Autogenous Arteriovenous Fistula (BBF) Group; 61.1%, 55.5% and 44.4% in the PTFE Group and 63.3%, 60% and 46.6% in the PCU Group. Infections occurred in 3.7% of BBF patients, in 8.3% of PTFE patients and 10% of PCU patients. First cannulation times were: 69± 17 (day) in BBF Group, 20 ± 5 (day) in PTFE Group and 10± 3(day) in PCU Group. BBF was observed to perform better than AVG in terms of primary and secondary patency and to result in low infection rates. On the other hand, first cannulation was performed earlier in both graft AVFs. There was no significant difference between PTFE and PCU in terms of our outcomes.

Outcomes after Arterial Reconstruction with Autogenous Vein Graft for Limb Salvage in Traumatized Extremity

Purpose: The patients with major vascular injuries in the traumatized extremity and underwent arterial reconstruction using autogenous vein grafts for limb salvage. This study aims to report the outcomes of arterial reconstruction with autogenous vein graft in patients.Methods: From February 2015 to April 2017, a study was retrospectively analyzed 13 patients with limb injuries caused by significant arterial damage and underwent arterial reconstruction using vascular autografts for limb salvage. Such as cause, Mangled Extremity Severity Scores (MESS), ischemic time, length of the grafted vein, reconstructed arterial status, and survival status were analyzed. Results: Among the patients analyzed, nine patients’ injuries were caused by traffic accidents and three industrial accidents, one fall down. Mean MESS was 6.2 (range, 5–8) and mean ischemic time was 12.3 hours (range, 5–25 hours). As arterial reconstruction, seven patients underwent posterior tibial artery reconstruction, three underwent popliteal artery reconstruction, two underwent anterior tibial artery reconstruction, and one underwent radial artery reconstruction; the greater saphenous vein was grafted in 12 reconstruction cases. Mean length of the grafted vein was 4.9 cm (range, 3–10 cm). All patients have salvaged injured limbs.Conclusion: Artery reconstruction using autogenous vein graft is an efficient treatment method when vascular damage cannot be directly repaired during limb salvage.

All-Trans Retinoic Acid Prevented Vein Grafts Stenosis by Inhibiting Rb-E2F Mediated Cell Cycle Progression and KLF5-RARα Interaction in Human Vein Smooth Muscle Cells.

Vein graft failure (VGF) is an important limitation for coronary artery bypass graft (CABG) surgery. Inhibition of the excessive proliferation and migration of venous smooth muscle cells (SMCs) is an effective strategy to alleviate VGF during the CABG perioperative period. In the present study, we aimed to explore the role and potential mechanism of all-trans retinoic acid (ATRA) on preventing vein grafts stenosis. The autogenous vein grafts model was established in the right jugular artery of rabbits. Immunohistochemistry staining and western blot assays were used to detected the protein expression, while real-time PCR assay was applied for mRNAs expression detection. The interaction between proteins was identified by co-immunoprecipitation assay. The Cell Counting Kit-8 and wound-healing assays were used to investigate the role of ATRA on human umbilical vein smooth muscle cells (HUVSMCs) function. Cell cycle progression was identified by flow cytometry assay. Vein graft stenosis and SMCs hyperproliferation were confirmed in vein grafts by histological and Ki-67 immunohistochemistry assays. Treatment of ATRA (10mg/kg/day) significantly mitigated the stenosis extent of vein grafts, demonstrated by the decreased thickness of intima-media, and decreased Ki-67 expression. ATRA could repress the PDGF-bb-induced excessive proliferation and migration of HUVSMCs, which was mediated by Rb-E2F dependent cell cycle inhibition. Meanwhile, ATRA could reduce the interaction between KLF5 and RARα, thereby inhibiting the function of cis-elements of KLF5. KLF5-induced inducible nitric oxide synthase (iNOS) expression activation could be significantly inhibited by ATRA. These results suggested that ATRA treatment may represent an effective prevention and therapy avenue for VGF.

Analysis of the effect of one-stage revascularization with internal carotid artery resection on cervical metastatic carcinoma in advanced head and neck carcinomas

Objective:To analyze the therapeutic effect of internal carotid artery resection and one-stage revascularization in advanced cervical metastatic carcinoma. Method:Twenty-one patients with advanced head and neck malignant tumors who underwent internal carotid artery resection and one-stage revascularization were analyzed retrospectively. Among those, 11 patients suffered from hypo-pharyngeal carcinomas, 5 laryngeal carcinomas, 2 external auditory carcinomas, 1 middle ear carcinoma, and 2 parotid gland carcinomas. All patients received CT, MRI, DSA and other examinations before operation. It was found that all the internal carotid artery walls had been invaded by tumors, and there were different degrees of lumen stenosis. Autogenous saphenous vein grafts were used in 18 cases; artificial vessels were used in 3 cases. After revascularization, pedicled or free flaps were used to protect the anastomotic areas. All patients were treated with radiotherapy and chemotherapy according to different situations. Result:Among the 21 cases, 16 cases underwent reconstruction of cervical segment internal carotid and 5 cases were the skull base segment internal carotid. Twenty patients were successfully reconstructed in the first stage, and no vascular reconstruction-related nervous system complications occurred after operations. Postoperative imaging showed that the reconstructed blood vessels were well recanalized, with a success rate of 95.2%（20/21）. Only 1 case received ligation of internal carotid artery after the failure of vascular reconstruction. Among all the cases, the 1-year survival rate and 3-year survival rate were 90.5% and 40.4%, respectively. Conclusion:In patients with advanced head and neck malignant tumors with cervical metastatic cancer invading the internal carotid artery, one-stage revascularization after radical resection of the tumor and the internal carotid can achieve good therapeutic effect. Careful preoperative evaluation, proficient vascular anastomosis technology, adequate risk assessment and prevention are the key to the success of the operations.

Extracorporeal resection of renal artery aneurysm and separate autogenous vein graft repair of its branches in a patient with retroaortic renal vein

Autopsy and intravital studies have reported the incidence of renal artery aneurysms (RAA) in 0.01 to 0.97% of the population. Fibromuscular dysplasia (FMD) and atherosclerosis are the main etiological factors for the development of RAA. The presence of abnormalities of the veins such as a retroaortic renal vein can significantly complicate the implementation of surgical interventions. The main methods to treat RAA are RAA resection with prosthetic repair, embolization of aneurysm cavities, and placement of an endograph. When aneurysm spreads to involve the renal artery branches or RAA is located in the kidney gates, the extracorporeal renal artery reconstruction is the only method to restore the renal vessels and keep a kidney. The article provides a rare observation of a patient suffering from renal artery fibromuscular dysplasia, left renal artery aneurysm with the development of vasorenal hypertension. The features of this clinical observation were the retroaortic left renal vein and the renal artery aneurysm located in the kidney gates. The patient underwent ureter-sparing extracorporeal autogenous vein graft repair of left renal artery branches. The surgery was performed using custodial solution for kidney pharmaco-hypothermic protection. Renal artery aneurysm was resected with the creation of a common junction of the renal artery branches followed by autogenous vein graft repair. The two lower segmental branches of the renal artery were separately prosthetized using the reversed autovein sections. Parietal injury to the left ureter was diagnosed in the patient in the postoperative period. A percutaneous needle-guided urine drainage bag was superimposed under ultrasound guidance with the placement of an integral stent in the injury area. The patient was discharged to outpatient care on Day 11. The urine drainage bag was removed two months after the control CTA. The integral stent was removed a month later, normal urine output was restored in the upper urinary tract. After 6 months, the control CTA showed that all reconstructed renal artery branches were completely patent, and blood pressure readings were within normal range.

In situ bypass and extra-anatomic bypass procedures result in similar survival in patients with secondary aortoenteric fistulas

ObjectiveThe optimal revascularization modality in secondary aortoenteric fistula (SAEF) remains unclear in the literature. The purpose of this investigation was to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients with SAEF. MethodsA retrospective, multi-institutional study of SAEF from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and operative and postoperative variables were recorded. The primary outcome was long-term mortality. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariate analyses were performed. ResultsDuring the study period, 182 patients at 34 institutions from 11 countries presented with SAEF (median age, 72 years; 79% male). The initial aortic procedures that resulted in SAEF were 138 surgical grafts (76%) and 42 endografts (23%), with 2 unknown; 102 of the SAEFs (56%) underwent complete excision of infected aortic graft material, followed by in situ (in-line) bypass (ISB), including antibiotic-soaked prosthetic graft (53), autogenous femoral vein (neoaortoiliac surgery; 17), cryopreserved allograft (28), and untreated prosthetic grafts (4). There were 80 patients (44%) who underwent extra-anatomic bypass (EAB) with infected graft excision. Overall median Kaplan-Meier estimated survival was 319 days (interquartile range, 20-2410 days). Stratified by EAB vs ISB, there was no significant difference in Kaplan-Meier estimated survival (P = .82). In comparing EAB vs ISB, EAB patients were older (74 vs 70 years; P = .01), had less operative hemorrhage (1200 mL vs 2000 mL; P = .04), were more likely to initiate dialysis within 30 days postoperatively (15% vs 5%; P = .02), and were less likely to experience aorta-related hemorrhage within 30 days postoperatively (3% aortic stump dehiscence vs 11% anastomotic rupture; P = .03). There were otherwise no significant differences in presentation, comorbidities, and intraoperative or postoperative variables. Multivariable Cox regression showed that the duration of antibiotic use (hazard ratio, 0.92; 95% confidence interval, 0.86-0.98; P = .01) and rifampin use at time of discharge (hazard ratio, 0.20; 95% confidence interval, 0.05-0.86; P = .03) independently decreased mortality. ConclusionsThese data suggest that ISB does not offer a survival advantage compared with EAB and does not decrease the risk of postoperative aorta-related hemorrhage. After repair, <50% of SAEF patients survive 10 months. Each week of antibiotic use decreases mortality by 8%. Further study with risk modeling is imperative for this population.

Inhibition Effect of Arresten Gene Transfection Combined with Nanoparticle-Mediated ENDOSTAR on Intimal Hyperplasia in Autogenous Vein Graft in Rats

Inhibition Effect of Arresten Gene Transfection Combined with Nanoparticle-Mediated ENDOSTAR on Intimal Hyperplasia in Autogenous Vein Graft in Rats

Clinical outcomes after wide resection of lower extremity soft tissue sarcomas with femoral vessel reconstruction

Introduction With advancements in local control of lower extremity soft tissue sarcoma (STS) by modern oncology protocols, limb salvage surgeries have become the standard of care with good results in both limb function outcome and quality of life. Patients and methods This is a retrospective analysis of all patients with a localized STS of the lower extremity presented to Vascular Surgery Unit at Faculty of Medicine, Cairo University, and who underwent en bloc vascular resection of the tumor between January 2018 and April 2019. Results We have found 17 patients during the study period. In three patients, iliofemoral arterial repairs were performed. Above-the-knee femoropopliteal bypasses were implanted in six patients. In four patients, popliteoposterior tibial bypasses were performed. Venous reconstructions consisted of three iliofemoral, one femorofemoral, and four femoropopliteal bypass reconstructions. Another four venous reconstructions were performed in the popliteal region. All patients developed moderate degree of pitting lower limb edema at the early postoperative period. Only one patient had undergone lower limb above-knee amputation. There was one synthetic Dacron graft occlusion in a patient with arterial bypass procedures. Regarding venous bypasses, occlusion occurred in three patients. Freedom from local tumor recurrence at 6 months was 64.2%. The freedom from distant metastases at 6 months after primary tumor excision was 85.7% for more than 10 mm margins and 20% for less than or equal to 10 mm margins. The cumulative overall survival proportion at 6 months was 53.9%. Conclusion Vascular reconstruction after wide local excision of lower extremity STS prevents the complications of vascular ligation and local recurrence in case of subradical excision. The use of autogenous vein graft yields better patency rates than synthetic grafts.

Cystic Arterial Disease Located Only in the Media of the Popliteal Artery: A Case Report.

Adventitial cystic disease of the popliteal artery is a rare non-atheromatous peripheral artery disease. In most cases, the cystic lesion is located in the adventitia of the popliteal artery. Herein, we present a rare case of cystic arterial disease in which the cyst was located only in the media of the popliteal artery. We successfully treated the cyst with resection of the affected popliteal artery and reconstruction with an autogenous vein graft.

Massive hematuria due to an autogenous saphenous vein graft and urinary bladder fistula in an extra-anatomic iliofemoral bypass: a case report

IntroductionGross hematuria caused by rupture of an artery in the urinary tract is a rare but potentially fatal condition. Iliac artery aneurysms, pelvic surgery with radiation, vascular reconstructive surgery, surgery for stenosis of the ureteropelvic junction, and transplantation are reported to be associated with this condition. In the vascular reconstructive surgery group, the most common etiology is rupture of the degenerated artery or synthetic graft in the ureter.Case presentationWe present a case of rupture of the small anastomotic pseudoaneurysm at the proximal anastomosis of a right iliofemoral autogenous vein extra-anatomic graft in the urinary bladder. To our knowledge, this is the first report of a rupture of an autogenous vein graft in the urinary bladder. Our patient, a 24-year-old Albanian farmer, was admitted to the emergency department in severe hemorrhagic shock induced by exsanguinating hematuria. He underwent immediate surgery, during which direct sutures to the bladder were placed and the saphenous graft was replaced with a synthetic one. The patient recovered completely, was free of hematuria, and showed no signs of pathological communication between the urinary and arterial tracts on postoperative cystoscopy and computed tomographic angiography during 2 years of follow-up.ConclusionThe incidence of artery-to-urinary tract fistulas is growing due to the increasing use of urologic and vascular surgery, pelvic oncologic surgery, and radiation therapy. In addition to fistulas involving a degenerated artery and ureter or synthetic grafts and ureter, they can also involve an autogenous vein graft and the urinary bladder. In our patient, the fistula was a result of erosion of the bladder from a pseudoaneurysm at the proximal anastomosis of an autogenous vein iliofemoral bypass in an extra-anatomic position. Open surgery remains the best treatment option, although there is increasing evidence of successful endovascular treatment.

Blunt Handlebar Injury of the Common Femoral Artery in a Pediatric Patient: Case Report

Introduction - Vascular non-iatrogenic trauma in pediatric population is rare. Generally, they are associated to bone fractures, stab or cut wounds. Less common is the blunt trauma as a cause of a vascular lesion. There are implications in the treatment of this kind of lesion associated to the pediatric anatomy, physiology and the growth potential of the pediatric patient. Mainly by the small size of the vessels, thickness of the veins wall or the vascular spasm of the arteries. It’s still controversial which is the best treatment option in these cases, with a wide range of options from medical treatment, direct repair, autogenous saphenous vein graft, ligation and endovascular stenting. Methods - We describe a case of a 9-year-old boy with a very small groin hematoma and an acute left limb ischemia grade IIa after a handle bike trauma 24 hours ago. Ultrasound and CT scan showed a common femoral artery occlusion as well as an absence of femoral vein thrombosis. Results - A surgical treatment was chosen. A common femoral artery approach showed a focal contained artery transection with thrombosis. An autologous panel saphenous vein graft interposition was performed to avoid graft size mismatch. An uneventful postoperative course was developed, and he was discharged 72 hours later. Conclusion - Blunt vascular trauma is a rare condition in pediatric population and clinical suspicion is necessary to avoid a diagnosis delay. The handlebar pressure on the femoral artery against femur or pubis bone may be a traumatic weapon even in not severe bike trauma. Special considerations and technical difficulties should be considerate in the surgical and medical pediatric treatment. There are different options of treatment that depends on the type of injury and the clinical situation. References1Sarfati MR, Galt SW, Treiman GS, Kraiss LW. Common femoral artery injury secondary to bicycle handlebar trauma. J Vasc Surg. 2002 Mar;35(3):589-91.2Mommsen P, Zeckey C, Hildebrand F, Frink M, Khaladj N, Lange N, Krettek C, Probst C. Traumatic extremity arterial injury in children: epidemiology, diagnostics, treatment and prognostic value of Mangled Extremity Severity Score. J Orthop Surg Res. 2010 Apr 15;5:25. doi: 10.1186/1749-799X-5-25.

Clinical efficacy of Da Vinci robot-assisted iliofemoral vein bypass grafting

Objective To explore the clinical efficacy of Da Vinci robot-assisted iliofemoral vein bypass grafting. Methods The retrospective descriptive study was conducted. The clinical data of one 66-year-old male patient who underwent Da Vinci robot-assisted iliofemoral vein bypass grafting in the First Affiliated Hospital of Army Military Medical University in March 2019 were collected. The patient was failed to recanalize iliofemoral vein stent thrombosis by endovascular measures and underwent Da Vinci robot-assisted iliofemoral vein bypass grafting after balloon occlusion preset in the common iliac vein. Observation indicators: (1) intra- and post-operative situations; (2) follow-up and survival situations. Follow-up using outpatient examination was performed to detect the patient′s postoperative survival and swelling reduction of affected extremity up to April 2019. Results (1) Intra- and post-operative situations: the patient underwent Da Vinci robot-assisted iliofemoral vein bypass grafting successfully. The operation time of balloon occlusion preset by digital subtraction angiography was 35 minutes. The operation time of Da Vinci robot-assisted iliofemoral vein bypass grafting was 502 minutes (50 minutes of exposure time of femoral vein, 80 minutes of exposure time of iliac vein, 40 minutes of great saphenous vein harvesting time, 70 minutes of end to side anastomosis between autogenous great saphenous vein and femoral vein, 10 minutes of subcutaneous tunnel construction, 90 minutes of end to side anastomosis between autogenous great saphenous vein and iliac vein, 60 minutes of suturing except vessel closure, 102 minutes of preparation time, check and washing time). The volume of intraoperative blood loss was 500 mL and no intraoperative complications occurred. The autogenous great saphenous vein graft was well filled and no bleeding was found at both proximal and distal anastomoses after iliofemoral vein bypass grafting. There were 4 abdominal Trocar holes including 2 of 1.2 cm and 2 of 0.8 cm. The incisional length of right groin and left great saphenous vein harvesting region was 5.0 cm and 15.0 cm, respectively. At the discharge time, the patient had swelling subsided partially at right lower extremity and skin tesion reduced significantly compared with the admission. The perimeters at 15 cm above right knee joint and left knee joint were 53.5 cm and 48.0 cm. The maximum perimeters of right calf and left calf were 41.0 cm and 38.0 cm. No postoperative complications occurred. Duration of hospital stay after surgery was 3 days. (2) Follow-up and survival situations: the patient was followed up for 1 month, with good survival. The patient had swelling subsided of affected extremity. The perimeters at 15 cm above right and left knee joint were 52.0 cm and 48.0 cm. The maximum perimeters of right calf and left calf were 40.0 cm and 38.0 cm. Conclusion The Da Vinci robot-assisted iliofemoral vein bypass grafting is safe and feasible, with good short-term outcomes. Key words: Vein thrombus; Da Vinci robotic surgical system; Vein; Bypass grafting; Minimally invasive surgery

Risk Factors of Amputation in Lower Extremity Trauma with Combined Femoropopliteal Arterial Injury.

PurposeThe clinical characteristics and results of femoropopliteal artery injury (FPAI) remain unclear. In this study, we evaluated the outcomes and risk factors of limb loss in patients treated for FPAI.Materials and MethodsWe retrospectively reviewed data from a database of patients who underwent revascularization for an FPAI at a single institution between January 2013 and December 2017. We reviewed and analyzed the characteristics, postoperative results, and factors that influence amputation rates.ResultsTwenty-four femoropopliteal arterial reconstructions in 24 patients were included in this study. Among the patients were 20 (83.3%) male with a first-quartile age of 28 years and a third-quartile age of 45 years (range, 15–68 years). The mean injury severity score (ISS) was 16 (range, 4–55), and 5 patients (20.8%) had ISSs of >20 points. The mean mangled extremity severity score (MESS) was 3.8 (range, 1–11), and 8 patients (33.3%) had MESSs of >5 points. In terms of arterial reconstruction methods, autogenous saphenous vein grafting, vein patching, and primary closure were performed in 9 patients (37.5%), 4 patients (16.7%), and 11 patients (45.8%), respectively. Despite arterial reconstruction, 5 patients (20.8%) underwent above-knee amputation. ISSs of >20, MESSs of >7, and orthopedic fixation were statistically significant factors associated with amputation.ConclusionIn cases of FPAI with ISSs of >20, MESSs of >7, and orthopedic fixation, amputations should be considered. We were also careful to attempt limb salvage in such cases.

Prevention of peritendinious adhesions in zone II primary flexor tendon repair using a vein patch graft: A comparative study

Adhesion after intrasynovial tendon injury is a major clinical problem. Here we assess autogenous vein graft over the primary flexor tendon repair to prevent postoperative peritendinious adhesions. Twenty-six patients (30 digits) had an acute flexor tendon injury in zone II. Primary tenorrhaphy was done using the traditional Kessler repair technique. Patients were divided into two groups according to the management of tendon sheath defects. In group I (n = 15 digits), a patch of a marked forearm vein was harvested, divided and sutured to the tendon sheath window. In group II (n = 15 digits), the tendon sheath was left untreated. Patients were evaluated using the second Buck-Gramcko scale at 8 weeks and 6 months. We detected no statistically significant difference between the groups. For the vein graft group, excellent results were achieved in four digits, five digits with very good results, five digits with good results and one digit with fair results. Using the traditional technique, excellent results were achieved in three digits, very good results were achieved in four digits, good results were achieved in six digits and fair results were achieved in two digits. The use of autologous vein graft has many advantages; it is inexpensive, autologous and will not affect tendon healing. Comparing autologous vein graft to the conventional tendon repair technique, we detected no statistically significant difference. Clinically, less adhesion formation and fewer joint contractures were noted when using the autologous vein graft. Level of Evidence: Level I, therapeutic study.

LEA3. Open Distal Revascularization in Chronic Kidney Disease: Is It Worthwhile?

The incidence of chronic kidney disease (CKD) has reached pandemic proportions across the world. Occlusive arterial disease causing critical limb ischemia and sepsis in the CKD patient is a huge clinical challenge often culminating in major amputation or mortality. Successful revascularization of these patients is challenging with added limitations due to impaired renal function, difficulties in contrast-enhanced imaging, heavily calcified arteries, and overall comorbid status. All patients with Fontaine stage IV critical limb ischemia with tibial occlusive disease for whom angioplasty was either contraindicated or unsuccessful were considered. All those with overwhelming sepsis that warranted primary amputation were excluded. A prospective single-center case-control study was done to evaluate the outcome of surgical revascularization in those with CKD (group 1, estimated glomerular filtration rate [eGFR] of 15-90 mL/min/1.73 m2), those with end-stage renal failure (ESRF; group 2, eGFR <15 mL/min/1.73 m2), and those with preserved renal function (group 3, eGFR >90 mL/min/1.73 m2). The mean ages of the three groups were 54, 58, and 51 years, respectively. The study period was December 2014 to December 2017; the 6-month patient survival, graft patency, limb salvage rates were compared. All had autogenous vein grafts with standardized surgical technique. There were 149 consecutive surgical revascularizations performed (group 1, 62; group 2, 28; group 3, 59). There was one perioperative death (group 1) on day 2. The respective rates of 6-month patient survival were 92%, 89%, and 93% (P > .05). The corresponding graft patency rates of group 1 and group 3 were 89% and 96% (P > .05), whereas limb salvage rates were 91% and 96% (P > .05). However, group 2 showed a significant decline in both graft patency (76%) and limb salvage (71%). Four patients (two in group 1, two in group 2) had below-knee amputations with a functioning graft because of advancing sepsis. There was no significant difference in graft patency or limb salvage in comparing those who had previously failed endovascular intervention with those who had primary surgical revascularization. The presence of advanced CKD including ESRF should not be considered a limiting factor in limb revascularization. Whereas meticulous planning and care are needed to safeguard and to preserve remaining renal functions as well as to optimize outcomes in those with ESRF, the resulting limb salvage results have been excellent.