Composite Graft Research Articles

Autotransplantation of Flaps in the Treatment of Peri-Implant Infection After Osteosynthesis (Analysis of Clinical Observations)

Unfortunately, suppuration of a postoperative wound remains the most frequent complication of surgical intervention. If suppuration is located superficially, within the subcutaneous fat, it can be successfully managed with minimal functional losses. The clinical course is significantly complicated if the focus of infection is located under the skin, in the thickness of the muscles, in the fracture zone. In the case of suppuration in the area of osteosynthesis, the complication may become critical.Such a complication is a serious condition that requires multi-stage complex and sometimes multidisciplinary treatment.The conditions for a successful outcome in this pathology are the minimum period from the moment of suppuration, active surgical tactics, stability of the implant, and good vascularization of the surrounding soft tissues.Active surgical tactics involves the opening and sanitation of purulent foci, leaks, recesses. Staged necrectomies are inevitable companions of surgical treatment and can cause the formation of defects in the skin, subcutaneous tissue, and muscles.The resulting soft tissue defect leads to exposure of the bone and plate. Removal of the metal fixator becomes inevitable.Only the closure of the defect with a complex of tissues based on free vascularized composite grafts can radically solve the problem.The article presents two clinical observations of deep wound infection after bone osteosynthesis, where autotransplantation of a vascularized flap was used. The use of this technique made it possible to achieve suppression of infection, wound healing by primary intention, to create conditions for consolidation of the fracture, restoration of function and preservation of the limb as a whole.

Controlled release of ciliary neurotrophic factor from bioactive nerve grafts promotes nerve regeneration in rats with facial nerve injuries.

It is critical to repair severed facial nerves, as lack of treatment may cause long-term motor and sensory impairments. Ciliary neurotrophic factor (CNTF) plays an important role in terms of enhancing nerve axon regrowth and maturation during peripheral nerve regeneration after injury. However, simple application of CNTF to the transected nerve site does not afford functional recovery, because it is rapidly flushed away by bodily fluids. The aim of the present study was the construction of a new, bioactive composite nerve graft facilitating persistent CNTF delivery to aid the reconstruction of facial nerve defects. The in vitro study showed that the bioactive nerve graft generated sustainable CNTF release for more than 25 days. The bioactive nerve graft was then transplanted into the injury sites of rat facial nerves. At 6 and 12 weeks post-transplantation, functional and histological analyses showed that the bioactive nerve graft featuring immobilized CNTF significantly enhanced nerve regeneration in terms of both axonal outgrowth and Schwann cell proliferation in the rat facial nerve gap model, compared to a collagen tube with adsorbed CNTF that initially released high levels of CNTF. The bioactive nerve graft may serve as novel, controlled bioactive release therapy for facial nerve regeneration.

Invited commentary to correspondence regarding our paper: “RE: "Hyperbaric oxygen therapy for large composite grafts: An alternative in pediatric facial reconstruction"

Invited commentary to correspondence regarding our paper: “RE: "Hyperbaric oxygen therapy for large composite grafts: An alternative in pediatric facial reconstruction"

“Nasal lining rotation flap with triangular fossa composite graft, an effective method for managing the multiply-revised Asian short nose”

Postoperative short nose is one of the most difficult problems encountered in plastic surgery. We propose a technique of lining rotation flaps combined with composite chondrocutaneous auricular graft from the triangular fossa to reconstruct the lining defect and improve surgical results. Twenty patients were operated on between 2016 and 2019 for postoperative short nose. Lining rotation flaps were used to supply missing medial mucosal lining with creation of a raw surface at the lateral lining in 10 patients (intervention group). A total of 17 composite chondrocutaneous grafts taken from the triangular fossa of the ears were used to resurface the defect. The other 10 patients received lining management using conventional techniques (control group). There was a near-complete take of 13/17 composite grafts (76.5%), with four partial losses that healed uneventfully. Anthropometric analysis of preop and postop profile photos showed statistically significant decreased nasolabial angle in both groups. The amount of derotation achieved was significantly increased (p<0.05) with our proposed method (Intervention group: 12.3±9.3° vs. control group: 6.55±4.5°). Donor sites healed uneventfully. Both groups of patients were satisfied with their results based on Rhinoplasty Outcomes Evaluation questionnaire. The lining rotation flap with triangular fossa composite graft is a safe and effective method for management of the postoperative short nose in Asians.

Impact of tibial bypass conduit on long-term amputation-free survival and primary patency in the Vascular Quality Initiative

ObjectiveMuch research remains focused on tibial bypass conduit selection. We sought to describe long-term amputation-free survival (AFS) and primary patency (PP) of patients undergoing tibial bypass by conduit type and configuration across several permutations in the Society for Vascular Surgery Vascular Quality Initiative. MethodsPatients in the Vascular Quality Initiative registry undergoing elective first-time femoral- or popliteal-to-tibial bypass for occlusive disease involving rest pain or tissue loss were identified. Prior ipsilateral infrainguinal bypass or concomitant procedures were excluded. Outcomes of interest included patient AFS at 22 months and PP at 1 year (defined as freedom from revision, thrombectomy, or graft occlusion). ResultsA total of 4192 bypasses were identified. The majority utilized great saphenous vein (GSV) (76.2%), followed by polytetrafluoroethylene (10.6%), nonautologous biologic (6.5%), composite (3.3%), arm vein (2.8%), and small saphenous vein (0.6%). Compared with all prosthetic and composite bypasses, vein grafts had the best AFS (76.4%; P < .0001) and PP (68.1%; P = .041). Of the single segment vein conduits, GSV bypasses had the best PP (69.1%) and arm vein the worst (60.2%). AFS and PP were similar between single-segment GSV orientations. Single-segment GSV bypasses exhibited better PP than multiple segment bypasses (69.1% vs 54.6%; P = .0016). PP was significantly better for polytetrafluoroethylene compared with nonautologous biologic (68.4% vs 51.2%; P = .0039). PP did not significantly differ between vein cuff for prosthetic bypass compared with no vein cuff (69.1% vs 59.7%; P = .091). PP was not significantly different between single-segment GSV and prosthetic grafts with vein cuff (69.1% vs 69.1%; P = .51). There were no significant differences in AFS comparing arm vein, prosthetic bypass with vein cuff, or composite grafts (67.2% vs 63.8% vs 59.3%; P = .092), as well as in PP (60.2% vs 69.1% vs 54.8%; P = .14). ConclusionsSingle-segment vein bypass was only marginally the most optimal conduit. Surprisingly, there may be more equipoise among conduit types, particularly in the absence of adequate GSV. Prosthetic grafts overall may not be as disadvantaged in the long term as initially thought, especially when compared with arm vein, as prosthetic bypass with vein cuff did not significantly differ in PP. Similarly, a composite conduit may not impact long-term outcomes. These data suggest that conduit choice may not impact outcomes to the degree previously thought and that other factors may have a greater impact than presumed, especially in conduit limited situations.

Auricular antitragus chondrocutaneous composite graft: A novel technique for reconstruction of full-thickness columella defects

Columellar necrosis often results in injury to the overlying columellar skin, the medial crura of the lower lateral nasal cartilages, the anteromedial inner nasal mucosa, and possibly the anterior septal cartilage.1 The auricular chondrocutaneous composite graft is one of the best reconstructive methods to date.2 Increasing graft size, however, increases the risk of graft failure and donor site deformity.

In vivo performance of electrospun tubular hyaluronic acid/collagen nanofibrous scaffolds for vascular reconstruction in the rabbit model

One of the main challenges of tissue-engineered vascular prostheses is restenosis due to intimal hyperplasia. The aim of this study is to develop a material for scaffolds able to support cell growth while tolerating physiological conditions and maintaining the patency of carotid artery model. Tubular hyaluronic acid (HA)-functionalized collagen nanofibrous composite scaffolds were prepared by sequential electrospinning method. The tubular composite scaffold has well-controlled biophysical and biochemical signals, providing a good matrix for the adhesion and proliferation of vascular endothelial cells (ECs), but resisting to platelets adhesion when exposed to blood. Carotid artery replacement experiment from 6-week rabbits showed that the HA/collagen nanofibrous composite scaffold grafts with endothelialization on the luminal surface could maintain vascular patency. At retrieval, the composite scaffold maintained good structural integrity and had comparable mechanical strength as the native artery. This study indicating that electrospun scaffolds combined with cells may become an alternative to prosthetic grafts for vascular reconstruction.Graphical

New perspectives in regenerative medicine and surgery: the bioactive composite therapies (BACTs)

Regenerative medicine and surgery is a rapidly expanding branch of translational research in tissue engineering, cellular and molecular biology.To date, the methods to improve cell intake, survival, and isolation need to comply with a complex and still unclear regulatory frame, becoming everyday more restrictive and often limiting the effectiveness and outcome of the therapeutic choices. Thus, the authors developed a novel 360° regenerative strategy based on the synergic action of several new components called the bioactive composite therapies (BACTs) to improve grafted cells intake, and survival in total compliance with the legal and ethical limits of the current regulatory frame.The rationale at the origin of this new technology is based on the evidence that cells need supportive substrate to survive in vitro and this observation, applying the concept of translational medicine, is true also in vivo. Bioactive composite mixtures (BACMs) are tailor-made bioactive mixtures containing several bioactive components that support cells’ survival and induce a regenerative response in vivo by stimulating the recipient site to act as an in situ real bioreactor. Many different tissues have been used in the past for the isolation of cells, molecules, and growth factors, but the adipose tissue and its stromal vascular fraction (SVF) remains the most valuable, abundant, safe, and reliable source of regenerative components and particularly of adipose-derived stems cells (ADSCs). The role of plastic surgeons as the historical experts in all the most advanced techniques for harvesting, manipulating, and grafting adipose tissue is fundamental in this constant process of expansion of regenerative procedures. In this article, we analyze the main causes of cell death and the strategies for preventing it, and we present all the technical steps for preparing the main components of BACMs and the different mixing modalities to obtain the most efficient regenerative action on different clinical and pathological conditions. The second section of this work is dedicated to the logical and sequential evolution from simple bioactive composite grafts (BACGs) that distinguished our initial approach to regenerative medicine, to BACTs where many other fundamental technical steps are analyzed and integrated for supporting and enhancing the most efficient regenerative activity. Level of Evidence: Not gradable

New Method for Preparing Small-Caliber Artificial Blood Vessel with Controllable Microstructure on the Inner Wall Based on Additive Material Composite Molding.

The diameter of most blood vessels in cardiovascular and peripheral vascular system is less than 6 mm. Because the inner diameter of such vessels is small, a built-in stent often leads to thrombosis and other problems. It is an important goal to replace it directly with artificial vessels. This paper creatively proposed a preparation method of a small-diameter artificial vascular graft which can form a controllable microstructure on the inner wall and realize a multi-material composite. On the one hand, the inner wall of blood vessels containing direct writing structure is constructed by electrostatic direct writing and micro-imprinting technology to regulate cell behavior and promote endothelialization; on the other hand, the outer wall of blood vessels was prepared by electrospinning PCL to ensure the stability of mechanical properties of composite grafts. By optimizing the key parameters of the graft, a small-diameter artificial blood vessel with controllable microstructure on the inner wall is finally prepared. The corresponding performance characterization experimental results show that it has advantages in structure, mechanical properties, and promoting endothelialization.

Improving Nasal Symmetry with the Alar Composite Graft: Technique and Outcome Assessments in Cleft Patients

Improving Nasal Symmetry with the Alar Composite Graft: Technique and Outcome Assessments in Cleft Patients

1313 Unusual Supraannular Aortic Root Intimal Tear in a Patient with Severe Aortic Regurgitation

Abstract We present an extremely rare case of occult supraannular aortic root intimal tear in a patient presenting with acute severe aortic regurgitation (AR) and a previously undiagnosed bicuspid aortic valve. A 41-year-old Africo-Carribean female presented to the emergency department with acute pulmonary oedema and increasing dyspnea on exertion. She had been treated empirically with antibiotics for a chest infection. Initial concerns were either aortic dissection or infective endocarditis. Transthoracic echocardiography (TTE) demonstrated a normal size left ventricle with hyperdynamic systolic function and severe AR. The patient was transferred to a tertiary cardiothoracic surgical centre for urgent surgical treatment in view of haemodynamic instability and acute AR. A gated computed tomography aortogram identified pulmonary oedema with an asymmetrically dilated aortic root (maximal diameter 45 mm). Despite advanced multimodality preoperative imaging, diagnosis was made intraoperatively and prompted Bentall procedure with mechanical aortic valve. After median sternotomy and initiation of cardiopulmonary bypass, a supraannular aortic intimal tear starting from the right coronary cusp/noncoronary cusp commissure was found with no extension into the aorta. The aortic valve was bicuspid and severe AR not amenable to repair was found. Bentall procedure was performed using the 23/26mm Carbomedics Carbo Seal Valsalva composite graft (Sulzer Carbomedics Inc, Austin, TX, USA). The patient was discharged on the 7th postoperative day in sinus rhythm. At 30-day clinical follow-up she was symptom free with a satisfactory TTE.

Reconstruction of Distal Nasal Defects With a Large Postauricular Skin-Fat-Fascia Composite Graft.

Composite grafts have previously been reported to achieve a good outcome for nasal defect repair, but composite grafts have greater metabolic needs than simple skin. Therefore, the traditionally recommended size of a composite graft for nasal reconstruction is less than 1.5 cm in diameter. However, the distal nose is generally well supplied with blood vessels, which might support the use of larger composite grafts in such a highly vascularized recipient site. The aim of the article is to investigate whether a large skin-fat-fascia composite graft (larger than 2.0 cm) is viable for the repair of partial-thickness nasal defects. From October 2017 to December 2019, 13 patients with partial-thickness nasal defects underwent nasal reconstruction using a large postauricular skin-fat-fascia composite graft. Cases were followed up for 3 to 14 months postoperatively. The aesthetic outcome was evaluated in comparison with preoperative digital images. Skin-fat-fascia composite grafts survived without graft necrosis, dermal fibrosis, or skin contraction in all cases. Favorable aesthetic outcomes were obtained in all patients, and no further revision surgery was need. A postauricular composite graft larger than 2.0 cm is a safe and effective reconstruction approach for partial-thickness nasal defects. This technique offers significant advantages in terms of no additional facial scar, no visible asymmetry on the face, no additional surgery for revision, and with mild scar in the donor site of the postauricular region.

Preparation and Characterization of Moldable Demineralized Bone Matrix/Calcium Sulfate Composite Bone Graft Materials.

Demineralized bone matrix (DBM) is a decalcified allo/xenograft retaining collagen and noncollagenous proteins, which has been extensively used because of its osteoconductive and osteoinductive properties. Calcium sulfate (CaSO4, CS) is a synthetic bone substitute used in bone healing with biocompatible, nontoxic, bioabsorbable, osteoconductive, and good mechanical characteristics. This study aims to prepare a DBM/CS composite bone graft material in a moldable putty form without compromising the peculiar properties of DBM and CS. For this purpose, firstly, porcine femur was defatted using chloroform/methanol and extracted by acid for demineralization, then freeze-dried and milled/sieved to obtain DBM powder. Secondly, the α-form and β-form of calcium sulfate hemihydrate (CaSO4·0.5H2O, CSH) were produced by heating gypsum (CaSO4·2H2O). The morphology and particle sizes of α- and β-CSH were obtained by SEM, and their chemical properties were confirmed by EDS, FTIR and XRD. Furthermore, the DBM-based graft was mixed with α- or β-CSH at a ratio of 9:1, and glycerol/4% HPMC was added as a carrier to produce a putty. DBM/CSH putty possesses a low washout rate, good mechanical strength and biocompatibility. In conclusion, we believe that the moldable DBM/CSH composite putty developed in this study could be a promising substitute for the currently available bone grafts, and might have practical application in the orthopedics field as a potential bone void filler.

Cystosonographic and Cystographic Evaluations of Urinary Bladder Defects Managed with Composite Colo-Peritoneal Grafts in Dogs

Radiographic and ultrasonographic evaluations of the urinary bladder architecture following autologous composite colo-peritoneal pedicle graft, as alternative tissue for urinary bladder reconstruction, in the surgical repair of experimental urinary bladder defects were carried out in two dogs. Predetermined 2 ´ 4 cm dimension of urinary bladder defect was created on the dorsum of the urinary bladder, and was patched with harvested 3 ´ 5 cm composite colo-peritoneal pedicle flap. All operations were aseptically and humanely conducted. The gross anatomical evaluation of the urinary bladder architecture was performed by ultrasonography and contrast radiography of the repaired urinary bladder. Post-surgical cystosonographic assessments on day 8 showed thickened urinary bladder wall at the point of the graft, which decreased markedly on day 21. Cystographic evaluation revealed gradual transition of the urinary bladder architecture at the point of graft with clear delineation and minimal blurring at week 2 post-operation, which gradually disappeared at weeks 10 and 14. The cystosonographic and cystographic evaluations demonstrated evidence of advanced healing and well-preserved urinary bladder architecture with no evidence of leaks. The imaging modalities are adequately diagnostic to assess urinary bladder repairs following its management with composite colo-peritoneal graft in dogs.

Controlling Pore Size of Electrospun Vascular Grafts by Electrospraying of Poly(Ethylene Oxide) Microparticles.

Electrospinning has become a popular polymer processing technique for application in vascular tissue engineering due to its unique capability to fabricate porous vascular grafts with fibrous morphology closely mimicking the natural extracellular matrix (ECMs). However, the inherently small pore sizes of electrospun vascular grafts often inhibit cell infiltration and impede vascular regeneration. Here we describe an effective and controllable method to increase the pore size of electrospun poly(ε-caprolactone) (PCL) vascular graft. With this method, composite grafts are prepared by turning on or off electrospraying of poly(ethylene oxide) (PEO) microparticles during the process of electrospinning PCL fibers. The PEO microparticles are used as a porogen agent and can be subsequently selectively removed to create a porogenic layer within the electrospun PCL grafts. Three types of porogenic PCL grafts were constructed using this method. The porogenic layer was either the inner layer, the middle one, or the outer one.

Improving Nasal Symmetry with Alar Composite Graft: Technique and Outcome Assessments in Cleft Patient

PurposeResidual cleft nasal deformities after initial cleft repair can have long-term cosmetic and psychological impact on patients. The authors describe a novel technique of an alar composite graft for patients with cleft lip and/or palate and assess the surgical outcomes with respect to symmetry of individual anatomical components. Materials and methodsThis was a retrospective study of patients with a history of cleft lip/palate who underwent rhinoplasty with alar composite graft placement by the senior author from March 2014 to January 2021. Patients who had high-quality pre-operative and postoperative 3D imaging were included. Patient age, sex, surgical history, cleft side, cleft details, and operative details were recorded. The primary operative technique includes the following: 1) Weir and sill excision at the donor side, 2) composite graft harvest, 3) Weir and sill incision at the recipient side, 4) graft placement, 5) closure of the incision sites. Three-dimensional imaging was obtained pre-operatively and postoperatively using Vectra M3 3D Imaging (Canfield Imaging System, Fairfield, NJ). Linear and surface area measurements were made on donor and recipient sides. The difference in measurements was calculated to analyze the degree of similarity across sides, and this difference was compared pre-operatively to postoperatively.1,2 Symmetry of the patient's nostrils and overall nasal symmetry was compared pre-operatively and postoperatively using root-mean-square deviation (RMSD), with smaller values indicating more symmetry. Differences between preoperative and postoperative measurements were calculated with a paired T-test. ResultsOut of 10 patients undergoing the surgery, 8 were able to be included in this study. On lateral view, the donor and recipient sides were more similar postoperatively compared to pre-operatively with respect to lateral alar-columellar disproportion (1.040 versus 3.324, P = .005) and nostril area (0.466 versus 1.065, P = .001) . On basal view, postoperative results showed more similar measurements comparing the donor and recipient sides in nostril height (1.461 versus 3.542, P = .012), nostril width (0.956 versus 2.222, P = .033), nasal dome height (1.597 versus 3.822, P = .024), and nostril surface area (0.188 versus 0.531, P = .015). On symmetry analysis, the overall external nose was more symmetrical after placement of the alar composite graft (1.094 vs 1.772, P = .015). ConclusionCleft lip and palate can cause significant asymmetry related to the nostrils, ala, and overall appearance of the nose. The alar composite graft is a useful technique to improve symmetry over a wide range of dimensions on lateral, basal, and frontal views.

Patient\u2019s perception of recovery after maxillary sinus floor augmentation with autogenous bone graft compared with composite grafts: a single-blinded randomized controlled trial

BackgroundAutogenous bone graft is considered as the preferred grafting material for maxillary sinus floor augmentation (MSFA). However, harvesting of extraoral or intraoral autogenous bone graft is associated with risk of donor site morbidity and supplementary surgery. From a clinical and patient perspective, it would therefore be an advantage, if postoperative discomfort could be minimized by diminishing the need for autogenous bone graft harvesting. The objective of the present study was to test the hypothesis of no difference in patient’s perception of recovery after MSFA with autogenous bone graft from the zygomatic buttress (control) compared with 1:1 mixture of autogenous bone graft and deproteinized porcine bone mineral (DPBM) (Test I) or biphasic bone graft material (BBGM) (Test II). Sixty healthy patients were randomly allocated to either control or test groups. Oral Health-related Quality of Life (OHRQoL) was evaluated by Oral Health Impact Profile-14 (OHIP-14) at enrollment. Recovery was estimated by self-administrated questionnaires and visual analog scale assessing pain, social and working isolation, physical appearance, eating and speaking ability, diet variations, sleep impairment and discomfort after 1 week and 1 month. Descriptive statistics was expressed as mean with standard deviation (SD). Correlation between OHRQoL at enrollment and recovery were assessed by linear regression. p-value below 0.05 was considered significant.ResultsTreatment satisfaction and willingness to undergo similar surgery were high in all groups. Average numbers of days with pain and sick leave were 3.5 (SD 3.9) and 0.5 (SD 1.2), respectively, with no significant difference between groups. Moreover, no significant difference in eating and speaking ability, physical appearance, work performance and sleep impairment were seen between groups. Mean OHIP-14 score at enrollment was 9.30 (SD 9.25) (control), 9.95 (SD 7.96) (Test I) and 8.15 (SD 9.37) (Test II), with no significant differences between groups. Impaired OHRQoL, gender or age seems not to predispose for delayed recovery or increased postoperative discomfort.ConclusionsMSFA with diminutive autogenous bone graft harvesting is associated with high patient satisfaction, limited postoperative discomfort and willingness to undergo similar surgery. Presurgical OHRQoL, gender or age seems not to be associated with impaired patient’s perception of recovery.

Multi-arterial Coronary Grafting

Arterial conduits, especially internal thoracic arteries (ITAs), are rarely affected by intimal hyperplasia or atherosclerosis, major contributors to early and late vein graft failure. Improved survival and freedom from reintervention with multi-arterial grafting (MAG) are reported in large observational studies, particularly when more than one anatomically important coronary territory is supplied. Several grafting configurations are possible depending on conduit and target characteristics, with the left ITA to the left anterior descending (LITA-LAD) typically being the cornerstone around which the rest of the conduits are constructed. The right ITA (RITA) or radial artery (RA) is used to bypass the second most important target after the LAD. The fundamentals of MAG depend on thorough preoperative evaluation, meticulous surgical technique and intraoperative flow assessment. Pitfalls to avoid include tension in short conduits or kinks in longer ones, poor ITA inflow, competitive native and graft flow, flow imbalance between segments of a composite graft, and sequentially grafting deep intramyocardial targets. Versatility and flexibility are critical in mitigating difficulties or potential complications in MAG. Refinements in complex bilateral ITA (BITA) and RA grafting require a deliberate iterative process that ideally incorporates dedicated training and mentorship by experienced MAG surgeons. Arterial conduits, especially internal thoracic arteries (ITAs), are rarely affected by intimal hyperplasia or atherosclerosis, major contributors to early and late vein graft failure. Improved survival and freedom from reintervention with multi-arterial grafting (MAG) are reported in large observational studies, particularly when more than one anatomically important coronary territory is supplied. Several grafting configurations are possible depending on conduit and target characteristics, with the left ITA to the left anterior descending (LITA-LAD) typically being the cornerstone around which the rest of the conduits are constructed. The right ITA (RITA) or radial artery (RA) is used to bypass the second most important target after the LAD. The fundamentals of MAG depend on thorough preoperative evaluation, meticulous surgical technique and intraoperative flow assessment. Pitfalls to avoid include tension in short conduits or kinks in longer ones, poor ITA inflow, competitive native and graft flow, flow imbalance between segments of a composite graft, and sequentially grafting deep intramyocardial targets. Versatility and flexibility are critical in mitigating difficulties or potential complications in MAG. Refinements in complex bilateral ITA (BITA) and RA grafting require a deliberate iterative process that ideally incorporates dedicated training and mentorship by experienced MAG surgeons. Corrigendum: Multi-arterial Coronary GraftingOperative Techniques in Thoracic and Cardiovascular SurgeryVol. 27Issue 4PreviewThe authors regret that in the article “Multi-arterial Coronary Grafting” by Rami Akhrass and Faisal G. Bakaeen in the Summer 2022 issue (27(2):126-146, 2022; https://doi.org/10.1053/j.optechstcvs.2021.09.001 ), (Figures 2 and 10) included an error with the course of the right internal thoracic artery (RITA). The corrected figures are included on the next 2 pages. Figure 2 was used as the cover image for the issue. In both Figures 2 and 10, the RITA should be anterior to the superior vena cava and posterior to the pulmonary artery. Full-Text PDF Commentary: Multiple Arterial Grafting for Coronary Artery Bypass Surgery: Choosing the Right Conduits for The Right Vessels for The Right PatientsOperative Techniques in Thoracic and Cardiovascular SurgeryVol. 27Issue 2PreviewDespite the known increased patency of arterial versus saphenous vein graft (SVG) conduits for Coronary Artery Bypass Graft (CABG) surgery, a recent Society of Thoracic Surgery (STS) national database study showed that while a single internal thoracic artery (SITA) graft was used in 89.4% of CABG patients, only 10.6% received multiple arterial grafts (MAG) and only 4.9% had bilateral internal thoracic artery grafts (BITA).1 What are the factors that have discouraged surgeons from embracing MAG and BITA grafting? In a 2018 national survey from the United Kingdom, almost one third of surgeons cited the lack of evidence in favor of MAG and BITA as a limiting factor for not adopting these techniques in their practices. Full-Text PDF Commentary: Time to Set New Standards for Coronary Bypass Surgery?Operative Techniques in Thoracic and Cardiovascular SurgeryVol. 27Issue 2PreviewAsk any cardiac surgeon who started their training in 90s, and you'll find that many of them, at some point, must have thought that surgical coronary revascularization was ill-fated. Especially in the mid 2000s, when drug-eluting stents appeared on the market and furtherly improved the outcomes of percutaneous revascularization1... God knew what would come next! History - and clinical trials - proved them wrong: almost 20 years later, coronary artery bypass grafting (CABG) is still the most common procedure in adult cardiac surgery and remains the gold standard for treatment of complex triple vessel disease and left main disease, particularly in younger patients and in case of diabetes or reduced left ventricular function. Full-Text PDF

Novel Mutation of the TGF-β 3 Protein (Loeys-Dietz Type 5) Associated With Aortic and Carotid Dissections: Case Report.

ObjectivesLoeys-Dietz syndrome (LDS) is a rare genetic cause of stroke associated with connective tissue disorders but is not well known among stroke physicians.1 The main objectives of this case report are to increase awareness of this condition and to improve stroke prevention at follow-up visits.MethodsA patient with aortic and carotid artery dissection who had undergone 2 major aortic surgeries with mechanical composite graft and treated with full-dose anticoagulation was reevaluated by neurologists due to retinal hypoperfusion symptoms. After musculoskeletal examination, cervical ultrasonography, and computerized tomography angiography, he was referred for whole-genome sequencing.ResultsWe found joint hypermobility, skin hyperelasticity, bifid uvula, and combined cervical artery dissections that caused intermittently decreased blood flow in the left ophthalmic artery and an acute asymptomatic embolic stroke. A novel pathogenic variant of LDS type 5 consisting of a heterogeneous nonsense variant c.1044C>A, p.(Cys384*) was found in the TGF-β 3 (TGFB3) gene. Consequently, anticoagulation was intensified, and at 1-year follow-up, the patient's symptoms improved.DiscussionThis novel genetic variant coupled to the patient's phenotype contributes to the knowledge of genetic causes of stroke. Patients with multiple arterial dissections and musculoskeletal features should be offered genetic testing and be carefully evaluated to avoid further cerebrovascular ischemic lesions.

Endoscopic inlay cartilage and perichondrium myringoplasty for repairing large perforations in teenagers

ObjectiveThis study compared the long-term graft success rates and hearing outcomes of overlay-underlay and underly cartilage myringoplasty for repairing large perforations in Teenagers.Study design: prospective, randomized study. SettingTertiary referral center. MethodsPediatric patients older than 12 years with chronic perforations were randomly divided into two groups:intervention group (n = 39) and control group (n = 41). The graft success rate, hearing improvement, and complications were compared between the two groups. ResultsA total of 80 patients were included in this study. The graft success rate was 100% in the intervention group and 95.1% in the control group at postoperative 3 months, the difference wasn't significant (P = 0.496). Also, the graft success rate was not significantly different between the two groups at 12 months postoperatively (100.0% vs 87.8%, p = 0.073). However, the difference of graft success rate was significant between the two groups at 24 months postoperatively (97.4% vs 75.6%, p = 0.012). CT examination revealed well-pneumatized middle ears 24 months after surgery in both group. However, epithelial pearls near the umbo were seen at 31 months postoperatively in one patient in the observation group. ConclusionsCompared to the endoscopic cartilage with perichondrium composite graft underlay technique, endoscopic perichondrial graft overlay and cartilage underlay had a better long-term graft success rate and lower rate of long-term re-perforation in teenagers. However, the graft technique had no effect on hearing outcome.