Autologous Interposition Graft Research Articles

Graft choice in pancreatectomy with vascular resection: equivalent safety in selected patients

BackgroundPancreatic cancer is the third leading cause of cancer-related death in the United States, with surgical resection being the only option for long-term survival. The ability to manage vascular involvement has expanded the pool of patients who are able to undergo resection with curative intent. However, not all vascular involvements can be detected preoperatively. This study aimed to investigate the patterns of vascular resection and methods of repair or reconstruction MethodsThis was a single-center retrospective review of adult patients undergoing pancreatectomy with vascular involvement at a tertiary care referral hospital between 2010 and 2022. The primary endpoint was graft thrombosis within 90 days. ResultsA total of 147 patients were included in the study. Of note, 21.8% of patients were not suspected of having vascular involvement preoperatively. Moreover, 68.0% of patients required vascular reconstruction, whereas the remaining 32.0% of patients underwent repair (either primary repair or patch angioplasty). Most patients who underwent reconstruction underwent primary end-to-end anastomosis (63.0%), with 19 patients requiring autologous interposition grafts and 16 patients requiring CryoVein interposition grafts. Univariate analysis found no clinical or technical predictors of early or 90-day thrombosis, including graft choice. In addition, 30- and 90-day mortalities occurred in 1 and 7 patients, respectively. ConclusionPancreatectomy with vascular resection can be performed with low mortality in carefully selected patients. Unsuspected vascular involvement is relatively common (1 in 5). If autologous graft is not readily available, CryoVein is a safe alternative with similar perioperative outcomes.

Anticoagulation after pancreatic surgery with venous resection (TIGRESS): What should we do? Results from an international survey.

Patients who undergo pancreatic surgery with venous resection have high rates of morbidity/mortality. Also, they are high-risk for postoperative venous thromboembolism. Whether this group should be routinely anticoagulated is unknown. This study aimed to establish current anticoagulation practices. A survey (https://form.jotform.com/220242489107048) was sent out to pancreatic surgeons. Questions covered center volume, venous resection/reconstruction techniques and anticoagulation policies. Sixty-five centers from 17 countries responded. Following a "side-bite" venous resection with a patch repair, 40% used an autologous vein patch, 27% used peritoneum, and 27% used a bovine patch. After formally resecting a segment of vein, 17% of centers used an interposition graft (IG). Left renal vein (41%) and polytetrafluoroethylene (73%) grafts were the most commonly used autologous and prosthetic IGs, respectively. Following a prosthetic IG, an autologous IG, and a "side-bite" resection, 59%, 28%, and 19% of centers provided therapeutic anticoagulation, respectively (66% used low molecular-weight heparin). The duration of therapy provided varied from inpatient stay only (14%) to six months (32%). Our global survey indicates that anticoagulation practices are highly variable. Centers do not agree on when to anticoagulate, how to anticoagulate, or the duration of therapy. A robust trial is required to provide clarity.

SP2.8 AnTIcoaGulation afteR pancreatic surgery with vEnouS reSection (TIGRESS): what should we do? Results from an international survey

Abstract Aims Patients who undergo pancreatic surgery with venous resection/reconstruction (PSVRR) have high rates of morbidity/mortality and are at risk of postoperative venous thromboembolism (VTE). It is unknown if this group should be routinely anticoagulated. We developed a survey to establish current anticoagulation practices among pancreatic surgeons. Methods A JotForm.com survey was sent to members of various hepatopancreatobiliary societies. Questions covered: centre volume, venous resection/reconstruction techniques, and anticoagulation policies. Results Sixty-five centres from 17 seventeen countries responded. Following a “side-bite” venous resection and patch repair, 40% use an autologous vein patch, 27% use peritoneum and 27% use a bovine patch. When formally resecting a segment of vein, 17% of centres use an interposition graft (IG). Left renal vein (41%) and polytetrafluoroethylene (PTFE, 73%) grafts are the most commonly used autologous and prosthetic IGs, respectively. Following a prosthetic IG, an autologous IG, and a “side-bite” resection with patch repair, 59%, 28%, and 19% of centres provide therapeutic anticoagulation (TAG), respectively. Among the units that provide TAG, most (66%) use low molecular weight heparin. The duration of therapy provided varies from inpatient stay only (14%) to six months (32%). Conclusions Our global survey indicates that anticoagulation practices following PSVRR are highly variable. The centres do not agree on when or how to anticoagulate, or the duration of therapy. A robust trial is required to provide clarity on these issues.

Autologous Interposition Grafts for Mucosal Flap Septal Perforation Repair.

Background: Nasal septal perforation repair is commonly attempted utilizing bilateral nasal mucosal flaps supported with an interposition graft. Objectives: To compare the failure rates for bilateral flap repairs utilizing four different autologous interposition grafts. Methods: This is a retrospective review of a single surgeon's bilateral flap perforation repairs supported with an autologous interposition graft. Study inclusion over the 18-year review period required at least one examination 1 month after surgery. Repair failure rates were calculated and compared for each graft type, and logistic regression was performed for multivariate analysis. Results: For the 356 study patients, median (range) age was 51 years (14-81) and 63.0% were women. Mean (range) perforation length was 13.9 mm (1-45). Median (range) at last follow-up was 11.2 months (1-192). Graft types used (percentage of patients and failure rate) were temporalis fascia (58.7/4.4), septal cartilage (23.3/7.3), auricular perichondrium (13.8/4.1), and septal bone (4.2/6.7) (p > 0.05). Conclusion: There was no significant difference in bilateral mucosal flap perforation repair failure rate when either a temporalis fascia, septal cartilage, auricular perichondrium, or septal bone interposition graft was used.

Total portal vein replacement with peritoneal interposition graft during Whipple’s procedure for extrahepatic cholangiocarcinoma: a technical report

BackgroundAggressive surgical resection in locally advanced hepatopancreatobiliary (HPB) malignancies is frequently advocated as the only potentially curative treatment. In recent years, advances in chemotherapy regimens and surgical techniques have led to improved oncologic outcomes and overall survival, by increasing the rates of radical (R0) resections. Vascular resections are increasingly reported to further increase disease clearance rates. Within this perspective, the issue of vascular reconstruction has raised growing interest, drawing particular attention to vascular substitutes and surgical techniques for reconstruction.Case presentationA case of extrahepatic cholangiocarcinoma with high clinical suspicion of vascular infiltration of the portal trunk at preoperative assessment is reported. An autologous interposition graft, harvested from diaphragmatic peritoneum, was chosen as a vascular substitute leading to successful portal trunk reconstruction and overcoming all possible drawbacks associated with cadaveric and artificial grafts reconstructions.ConclusionThis solution was strategic to ensure complete oncologic clearance averting the risk of positive margins (R1) at final pathology.

Postoperative Anticoagulation in Vascular Reconstructions Associated with Malignancies

The invasion of truncal arteries and veins by malignant neoplasms is rare and the surgical treatment remains a challenge. Several techniques can be used to re-establish blood flow in a resected vessel and choice of the ideal vascular substitute frequently arises a debate. Comparative studies between prosthetic and autologous grafts disclose conflicting patency results. The aim of this study is to compare patency outcomes of vascular reconstructions performed using autologous or prosthetic replacement grafts in surgical oncology, in light of a standardized antithrombotic protocol used in our institution since1997. This retrospective study compared patency of prosthetic versus autologous interposition grafts following the resection of malignancies in 117 patients between September 1997 and February 2020. The 181 reconstruction procedures performed were analyzed according to the body segment involved, and divided into: head and neck, thorax, abdomen, and extremities. Overall survival estimates after 24 and 60months were 53.2% (standard error 4.8%) and 38.1% (standard error 4.9%), respectively. No significant difference was observed between overall arterial patency, using autologous or synthetic grafts (P=0.41). Overall venous patency showed a tendency to be lower in synthetic grafts, although no significant difference was observed (P=0.062). For both arterial and venous reconstructions in the extremities (upper and lower limbs), significantly higher patency was observed using autologous grafts. Autologous long-term graft patency may be superior to prosthetic in vascular reconstructions associated with malignancies of the extremities. This outcome was obtained using a standardized post-operative anticoagulation protocol.

Optimizing Limb Salvage in Shotgun Injuries to the Extremities in Civilian Trauma

Vascular trauma in civilian settings has often resulted in high rates of amputation or mortality. Although treatment was individualized, patients were managed according to the following protocol: (1) Clinical evaluation and identification of those patients that require immediate exploration. (2) Determination of ankle-ankle indices, with a threshold of 0.9 mandating further evaluation. (3) Liberal use of computed tomography angiography (CTA) evaluation of injuries. (4) Selected use of digital subtraction angiography with an attempt to treat via endovascular means if there is thought to be a reasonable likelihood of success. (5) Liberal use of fasciotomy. (6) Reconstruction of arterial injury with contralateral reversed saphenous when available. (7) Postoperative follow-up with noninvasive arterial studies. Hypothesis: Protocol-driven early assessment and intervention can lead to excellent limb salvage in patients with civilian gunshot wound to the extremities. We retrospectively reviewed our gunshot database from 2012 to 2017 for patients with noniatrogenic penetrating vascular extremity injuries. Data analyzed were demographics, mode of injury, vessels injured, physical examination, arteriography findings, ischemic time, type of arterial and venous repair, morbidity, mortality, graft patency and functional outcome. Postoperative follow-up was done with noninvasive arterial studies. Sixteen patients sustained extremity injuries inflicted by shotguns. Fifteen (94%) underwent preoperative arteriography or CTA, revealing occult arterial injury in nine patients. One patient had soft tissue only and the other five who underwent CTA had no evidence of vascular injury. Forty-five percent of patients sustained concomitant venous injury; 64% of all venous injuries and 90% of femoropopliteal venous injuries were repaired. Eighty-one percent underwent fasciotomy at time of surgery. Fasciotomy occurred in 100% of patients with combined arterial and venous injuries (100%) versus 25% with isolated arterial injury. Arterial continuity was restored by interposition grafting with reversed saphenous vein (100%). There were no deaths or amputations at in-office follow-up, which ranged from 6 months to 7 years. Two patients had saphenous nerve injures, one of which fully recovered and the other patient ambulated with a cane due to nerve injury. A protocol of preoperative imaging with either arteriography or CTA for extremity shotgun injuries, use of fasciotomy, frequent use of autologous interposition grafts, repair of major venous injuries, and routine use of completion arteriography can result in limb salvage rates of 100% after shotgun vascular trauma to the extremities.

Pancreaticoduodenectomy with vascular resection: margin status and survival duration

Major vascular resection performed at the time of pancreaticoduodenectomy (PD) for adenocarcinoma remains controversial. We analyzed all patients who underwent vascular resection (VR) at the time of PD for any histology at a single institution between 1990 and 2002. Preoperative imaging criteria for PD included the absence of tumor extension to the celiac axis or superior mesenteric artery (SMA). Tangential or segmental resection of the superior mesenteric or portal veins was performed when the tumor could not be separated from the vein. As a separate analysis, all patients who underwent PD with VR for pancreatic adenocarcinoma were compared to all patients who underwent standard PD for pancreatic adenocarcinoma. A total of 141 patients underwent VR with PD. Superior mesenteric-portal vein resections included tangential resection with vein patch (n=36), segmental resection with primary anastomosis (n=35), and segmental resection with autologous interposition graft (n=55). Hepatic arterial resections were performed in 10 patients, and resections of the anterior surface of the inferior vena cava were performed in 5 patients. PD was performed for pancreatic adenocarcinoma in 291 patients; standard PD was performed in 181 and VR in 110. Median survival was 23.4 months in the group that required VR and 26.5 months in the group that underwent standard PD (P=0.177). A Cox proportional hazards model was constructed to analyze the effects of potential prognostic factors (VR, tumor size, T stage, N status, margin status) on survival. The need for VR had no impact on survival duration. In conclusion, properly selected patients with adenocarcinoma of the pancreatic head who require VR have a median survival of approximately 2 years, which does not differ from those who undergo standard PD and is superior to historical patients believed to have locally advanced disease treated nonoperatively.

Optimal limb salvage in penetrating civilian vascular trauma

To evaluate current treatment of peripheral vascular trauma, we reviewed our recent experience with noniatrogenic penetrating vascular injuries of the extremities. Between 1979 and 1984, 139 patients sustained 204 vascular injuries inflicted by single gunshots (64%), stabbings (24%), and shotguns (12%). Eighty-four percent of patients underwent preoperative arteriography, which revealed occult arterial injury in 13 patients (9%). Compartmental hypertension necessitated fasciotomy in 19% of patients and was required more often after combined arterial and venous injuries (29%) than after isolated arterial injury (14%). Arterial continuity was restored by interposition grafting with reversed saphenous vein (62%), end-to-end anastomosis (19%), vein patch angioplasty (8%), or primary repair (4%). After arterial repair, completion angiography detected the need for revision in 8% of patients. Arterial ligation was performed in 7% of injuries and was only used in the treatment of tibial and distal profunda femoris injuries. Forty-five percent of patients sustained concomitant venous injury; 64% of all venous injuries and 90% of femoropopliteal venous injuries were repaired. No deaths occurred, and a single patient required amputation. We conclude that a protocol of preoperative arteriography, liberal use of fasciotomy, frequent use of autologous interposition grafts, repair of major venous injuries, and routine use of completion arteriography can result in limb salvage rates that approach 100% after penetrating vascular trauma to the extremities.