Carrel Patch Research Articles

Donor Aortoplasty for Transplantation of Kidneys with Multiple Arteries

Due to the severe shortage of organs for transplantation, newer surgical techniques have been designed to use all compatible organs that may have been discarded because of anatomical arterial variations. The techniques for miniaturization of the extended Carrel patch, Carrel patch capping of the aorta and S-aortoplasty are illustrated.

New composite graft repair for patients with and without Marfan's syndrome

We developed a new composite graft repair technique to prevent the complications associated with Bentall-type procedures. The technique consists of the creation of a double proximal suture line and direct coronary artery implantation as a Carrel patch without wrapping. We retrospectively compared the outcome in patients with Marfan's syndrome (n = 16) and other disorders (aortitis, 11 patients; degenerative disease, 18 patients) who had undergone this procedure. In patients with Marfan's syndrome, there was one hospital death and six deaths during long-term follow-up. Among patients with Takayasu's arteritis, there was one hospital death and one late death. There was one late death in the patients with degenerative disease. No mortality or complications directly related to the surgical procedure occurred in any group. The high late mortality in patients with Marfan's syndrome was primarily due to distal aortic dissection or rupture. Thus, the major complications associated with Bentall-type procedures can be prevented through the use of our new composite graft technique. However, close serial follow-up, careful blood pressure control, and early detection and treatment of distal recurrence are mandatory in the postoperative management of patients with Marfan's syndrome.

HEPATIC ARTERY ANATOMY IN RELATION TO RECONSTRUCTION IN LIVER TRANSPLANTATION: SOME UNUSUAL VARIATIONS

The anatomy of the hepatic artery and its variations were studied in 70 donor livers harvested for liver transplantation in the Austin Hospital. Forty three (61.5%) had a 'normal' vascular anatomy and 27 (38.5% had anomalous anatomy. The anomalies were single in 13 instances and multiple in 14 and involved the origin of the right or left hepatic arteries or the coeliac axis. The hepatic artery was reconstructed most frequently by end-to-end anastomosis of the donor to the recipient common hepatic artery (79%). A Carrel patch, an interposition aortic graft and the donor superior mesenteric artery were other techniques used for reconstruction. Two patients (3%) had a postoperative hepatic artery thrombosis, with one of those patients having a further reconstruction. When one vascular anomaly is found, there is a high probability of others being present. The authors' experience confirms that safe hepatic arterial anastomosis can be performed even in the presence of abnormalities of the vascular arterial system.

New modified bentall procedure: Carrel patch and inclusion technique

In Bentall-type procedures, the bleeding and dehiscence occurring around the coronary ostial anastomosis still remain major complications. To reinforce the coronary anastomosis and shorten the time required for homostasis, a Carrel patch and inclusion technique was employed without any subsequent complications in 13 patients. We excised the coronary ostium with a collar of the aortic wall while leaving epicardium on the aortic wall, anastomosed it to the composite graft, and then included the graft with the aortic wall.

Small bowel transplantation in the mouse: development of a model.

The rat has been used as a model to study the significance of graft and host interactions in small bowel transplantation (SBTX). A mouse model of SBTX would allow investigators to apply the knowledge of the well-defined genetics in the mouse to this field of study. Therefore, we have developed a mouse model of heterotopic SBTX using syngeneic C57BL6/J mice. Animals were anesthetized with a combination of ketamine and xylazine. Donor animals underwent midline laparotomy, with isolation of a segment of bowel as an isograft for transplantation to a recipient animal. The bowel was flushed in situ prior to removal of the graft with a Carrel patch of aorta and portal vein. The recipient animal underwent midline laparotomy and preparation of its infrarenal aorta and inferior vena cava for end-to-side anastomosis of the graft with 10-0 nylon. After vascular reperfusion of the graft the ends of the isografted bowel were brought out as stomata. Successful grafts were later assessed for viability by laparotomy or histological examination at the time of sacrifice. Areas of technical difficulty in this model and issues that might improve the experimental results are discussed. This model should allow investigators to apply the well-defined genetics of the mouse to probe the challenging field of intestinal transplantation.

大動脈炎によるＡＡＥに対する大動脈基部再建法での縫合不全予防の工夫

大動脈炎によるＡＡＥに対する大動脈基部再建法での縫合不全予防の工夫

VENOUS RECONSTRUCTION OF PEDIATRIC EN-BLOC KIDNEYS FOR TRANSPLANTATION

Even though cadaveric kidneys are a scarce resource, pediatric kidneys are frequently discarded because of the small size of the organs or because of damage to the specimen during the procurement. In the latter circumstance, backtable reconstruction can be used (1). We report here the successful use of a set of 6-antigen-matched pediatric kidneys that had sustained a major procurement injury. The recipient was a 24-year-old woman with endstage renal disease secondary to insulin-dependent diabetes mellitus. Her HLA type was A2, 30 B28, 62 DR3, 4. A 6-antigen-matched set of pediatric en-bloc kidneys from a three-year-old donor was offered for her and accepted. When the kidneys were examined, it was noted that the vena cava had been split in half and was unusable (Fig. 1). A segment of fresh iliac vein graft from an adult cadaveric donor of the same blood type was taken from the refrigerator (Fig. 2). A Carrel patch of vena cava was left on each renal vein, and anastomosed end-to-side to the iliac vein graft with running 8–0 Novafil (Fig. 3). The superior end of the vein graft was closed with running 6–0 prolene. The donor aorta was prepared in the usual way, ligating the lumbar and other branches, and oversewing the aorta superiorly. The reconstructed kidneys were revascularized after a cold ischemia interval of 30 h and 29 min. Separate ureteroneocystostomies were performed. The kidneys functioned immediately and the patient was discharged 12 days later with a creatinine of 1.3 mg/dl. She remains well 13 months postoperatively with a creatinine of 1.1 mg/dl. Figure 1 Pediatric en bloc kidneys with divided inferior vena cava. Figure 2 Vein graft interposition. Figure 3 After reconstruction. Although arterial and venous reconstruction with stored vessel grafts often has been used successfully to salvage damaged kidneys (1), the type of problem described here with en-bloc kidneys had not been previously encountered. The kind of reconstruction used requires meticulous technique but is not particularly difficult. Magnification with surgical loupes is an invaluable aid. This salvage technique should be useful, albeit in a small way, to help increase the number of organs available for transplantation. Wengerter et al. (2) have emphasized that pediatric kidneys, which are often discarded because of their small size, can be used for adults.

The use of the hypogastric artery in the anastomosis of multiple renal arteries in the transplant patient

Alternative techniques for handling multiple renal vessels in living related kidney transplants by use of the hypogastric artery are presented. This vessel can be used either as a tubular vascular graft or as a Carrel patch graft. Details of these techniques are discussed.

The hepatic artery in liver transplantation.

Hepatic artery complications after liver transplantation are uncommon, but represent an important cause of morbidity and mortality. In addition, these complications tax an already limited supply of donor organs because of the frequent need for retransplantation in this group of patients. In this study, we examined the incidence of hepatic arterial anomalies in donors and recipients of orthotopic liver transplants, focusing on the techniques that are available for hepatic arterial reconstruction and on the occurrence of hepatic arterial complications. A total of 77 liver transplants were carried out in 68 patients. Standard recipient anatomy was present in 60 of 68 patients (88%). Anomalous vessels were identified in eight patients (12%), including six cases of replaced right hepatic artery (9%) and two cases of replaced left hepatic artery (3%). Donor liver arterial anatomy was standard in 62 cases (80%). Anomalous arterial supply was identified in 15 of 77 donor livers (20%), including replaced left hepatic artery in nine (12%) and replaced right hepatic artery in six (8%). A variety of methods were used to manage the anomalous vessels. There was one hepatic artery pseudoaneurysm, three cases of hepatic artery thrombosis (4%), and one patient developed a dissection of the native celiac axis. In primary transplants, utilization of the recipient's proper hepatic artery was associated with a significantly higher risk of hepatic artery thrombosis (P less than 0.04) when compared with the common hepatic artery or the branch patch technique. Use of a Carrel patch on the donor artery was associated with a significantly reduced incidence of hepatic artery thrombosis (P less than 0.0003). For retransplantation, it is recommended that a more proximal recipient anastomotic site be chosen. An innovative method is described that provides increased length of the donor arterial supply without the use of an arterial graft.

Arterial mycotic aneurysm and rupture. A potentially fatal complication of pancreas transplantation in diabetes mellitus.

Mycotic aneurysm at the site of a Carrel patch arterial anastomosis occurred in four patients who had undergone whole pancreas transplantation 2.5 to 14.5 months previously. In all patients, the graft had been removed, leaving the Carrel patch on the iliac artery. The aneurysms ruptured into the intestine or the extraperitoneal space. The ruptures were sudden and life-threatening in three of four cases. This diagnosis must be suspected in patients with a history of pancreas transplantation in the immediate or distant past if they present with unexplained hypotension, cardiac arrest, or gastrointestinal tract bleeding.

Canine Pancreaticoduodenal Allotransplantation with Cystoduodenostomy: An Animal Model with Clinical Application

Most techniques described in animal models of pancreatic transplantation use either segmental or autotransplants. We employ a technique of pancreaticoduodenal allotransplantation in the dog that closely resembles the operation used in humans. The arterial supply of the entire pancreatic graft is preserved by procuring a Carrel patch of aorta encompassing the origin of the celiac and the superior mesenteric arteries. Splenic, inferior pancreaticoduodenal, and superior pancreaticoduodenal arteries remain intact with the graft. Venous drainage is through a short segment of portal vein. A 6-cm cuff of duodenum is taken with the head of the pancreas. Engraftment proceeds by placing the allograft within the peritoneal cavity of the recipient. End-to-side vascular anastomoses are constructed to distal aorta and inferior vena cava. The duodenal cuff is anastomosed to the dome of the bladder for drainage and analysis of exocrine secretions and to provide a port of entry for cystoscopically directed needle biopsy. A total pancreatectomy is performed to induce a state of diabetes. The average operating time is 5 h. Twenty-two dogs have undergone allotransplantation using this technique. Six dogs had no complications and were sacrificed after meeting criteria of their study protocol. There were three technical failures, two arterial thromboses and one exsanguination, yielding an 86% rate of successful engraftment. Three other dogs died of intussusception and three dogs died of sepsis, one secondary to wound dehiscence and one due to inadvertent common bile duct ligation during pancreatectomy. Wound problems, four dehiscences and two superficial infections, occurred only in immunosuppressed dogs.

Operation for ascending aortic aneurysm and aortic regurgitation--pathological influence on survival.

The author briefly reviews the early operations of treatment of aortic aneurysm and aortic regurgitation leading to his description, in 1968, of the first composite graft replacement of the ascending aorta and aortic valve, with anastomosis of the coronary arteries into the graft. The original operation is described with reference to modifications suggested by a number of authors throughout the last 20 years. Methods of achieving coronary artery continuity by Carrel patch and pull-through by saphenous vein interposition and by synthetic graft techniques are discussed. While any of these methods may be needed in individual cases the preference of the author remains for simplicity. The arguments for and against excision of the aneurysmal sac are considered in relation to the control of haemorrhage. The early and medium term results of operation are good but in comparing results world-wide a lack of uniform diagnostic criteria is apparent. The full clinical Marfan syndrome presents little difficulty but the status of "annuloaortic ectasia", Erdheim's medionecrosis, "cystic medial necrosis" and many other pathological descriptions are not defined: "forme fruste" of Marfan's disease has been used for any of the above. Interpretation of surgical results remains difficult and often impossible in the absence of clear definitions. Recent work on elastic tissue and on the chemistry of collagen together with the hope of identification of the genetic background now offers real hope of clearer understanding.

The first 100 liver transplants at UCLA.

A clinical program in liver transplantation was begun at UCLA in 1984 after a period of laboratory investigation. The first 100 orthotopic liver transplants (OLT) were performed in 83 patients (43 adults and 40 children) between February 1, 1984 and November 1, 1986. Donors and recipients were matched only for size and ABO blood group compatibility, with OLT performed across blood groups in 28 patients. Standard operative techniques were used, including venous-venous bypass in adults. Arterial reconstruction was performed using an aortic Carrel patch or "branch patch" in 65% of cases and by end-to-end or aortic conduit techniques in the remainder. The hepatic artery thrombosis rate was 5%. Biliary reconstruction was choledochocholedochostomy in 67 OLT and Roux-en-Y choledochojejunostomy in 33 (complication rate of 24% and 24%, respectively). Average lengths and ranges of donor liver ischemia, operating time, and blood replacement were 4 hours (range: 1-10 hours), 7.6 hours (range: 4-15 hours), and 17 units packed cells (range: 2-220 units). Immunosuppressive regimen was cyclosporine-steroid combination, with monoclonal anti-T-cell antibody (OKT3) used for refractory rejection. All patients had one or more complications: pulmonary (78%), infectious (51%), renal dialysis (25%), neurologic (22%). All patients had at least one episode of acute rejection, and 3.6% had chronic rejection. Retransplantation was needed in nine patients once and in four patients twice. The overall retransplant survival rate was 54%, and two of four patients who received a second retransplant are alive. Sixty-three of the 83 patients (76%) are alive (adults 72%, children 80%). The 1- and 2-year actuarial survival rate is 73% (adults 68%, children 78%). Thirty-eight of 43 patients (88%) who had transplantation in the past year are alive. Of 14 perioperative variables assessed as predictors of early mortality, only postoperative dialysis (p less than 0.0005) and presence of severe rejection (p less than 0.01) had statistical significance. Seventy per cent of adults returned to work, and 84% of children had normal or accelerated growth. A new program in liver transplantation provides a dramatic option in patient care and an academic stimulus to the entire medical center.