Coronary Vein Research Articles

Problems of the Diagnosis and Treatment of Acute Mesenteric Ischemia: a SingleCenter Experience

Objective: To improve the diagnosis and treatment of acute mesenteric ischemia by using available methods of early diagnosis and modern methods of treatment. Summary Background Data: The number of patients with disorders of the mesenteric circulation is increasing all over the world. In comparison with the occlusion of the coronary, cerebral arteries and peripheral veins, acute obstruction of the mesenteric arteries and veins is diagnosed much later, which causes a high mortality rate from 53 to 100%. Methods: In this study the experience of treatment of 162 patients with acute mesenteric ischemia was analyzed. All patients underwent treatment in Institute of Urgent and Recovery Surgery (IURS NAMS, Donetsk, Ukraine) from 2002 to 2017. Results: From 162 patients: 112 patients were with acute occlusive and 50 patients with acute nonocclusive mesenteric ischemia. The intravital diagnosis was not confirmed in 26 patients (16 %). 119 of patients died, the level of mortality was 73, 5%. 104 patients were operated, 32 patients were discharged (30,8 %), 72 patients died, a mortality rate was 69,2 %. Operations with restore of blood flow were performed in 14 patients, 5 patients died, 9 patients left the hospital. Conservative therapy was performed in 22 patients, in 11 patients with good results (50 %). Conclusions: The early diagnosis of this pathology is crucial and it can reduce the high mortality rate of patients with AMI. Treatment of OAMI should be carried out in a community of general, vascular and endovascular surgeons. Restoration of blood flow through mesenteric vessels with the help of endovascular technology and implementation of thrombembolectomy during open surgical intervention in a number of cases allows to avoid intestinal resection.

Coronary vein defibrillator coil placement in patients with high defibrillation thresholds.

BackgroundElevated defibrillation threshold (DFT) occurs in 2%‐6% of patients undergoing implantable cardioverter defibrillator (ICD) implantation. Adding a defibrillation coil in the coronary sinus (CS) or its branches can result in substantial reductions in the mean DFT. However, data regarding acute success and long‐term stability remain lacking. We report our experience with this bailout strategy.MethodsPatients with elevated DFT at implantation (safety margin at implantation <10 J) and those with failed ICD shocks for ventricular arrhythmias (VA) referred for high DFT underwent placement of an additional defibrillation coil in the CS. DFT testing was performed at the completion of the implantation procedure. External potentially reversible factors were excluded. High‐output devices were systematically used.ResultsFour patients with high DFT at implantation and two with several failed shock attempts underwent placement of a defibrillation coil in the CS. Mean age was 41.8 (23‐78). They presented a mean LVEF of 21% (15‐30), QRS‐complex duration of 109.8 milliseconds (87‐168), body surface area of 1.96 m2 (1.45‐2.58), and a mean R wave of 16.3 mV (8‐27). Defibrillation coil implantation in the CS (final shocking configuration of right ventricle as anode and left ventricle (LV) plus can as cathode) was associated with successful DFT testing in all. Three patients had a concomitant LV lead for biventricular pacing. During a mean follow‐up of 54.67 months (10‐118), two patients experienced successful ICD shocks for VA (one of them also presented inappropriate shocks because of the fast conducting atrial fibrillation).ConclusionsPositioning of a defibrillation coil in the CS can result in a substantial reduction in mean DFT and associates with optimal long‐term stability.

Abstract 17042: Ketone Body Utilization is Suppressed in Patients With Ischemic Heart Disease

Introduction: Ketone bodies (acetoacetate, acetone, and β-hydroxybutyrate [βOHB]) are well-known energy substrates. Recent reports revealed that heart failure augmented the utilization of ketone bodies. However, little is known about the effects of an ischemic condition on the utilization of ketone bodies. Hypothesis: Myocardial ischemia suppresses ketone body utilization. Methods: We retrospectively enrolled 171 consecutive patients who were planned to undergo acetylcholine (ACh) provocation test. Lactate and βOHB concentrations at the aortic root and coronary sinus were simultaneously measured. Coronary lactate production (CLP) was defined lactate concentration at the coronary sinus was greater than that in the aortic root and indicated enhancement of anaerobic metabolism. Subjects were divided into two groups according to the CLP at baseline (CLP (+): n=32, CLP (-): n=121). Subsequently, to assess the acute effect of myocaridal ischemia, subjects of CLP (-) at baseline were further grouped into two groups according to CLP after ACh provocation test (Provoked-CLP (+), n=81; Provoked-CLP (-), n=40). βOHB extraction rate as follows; {[Concentration at aortic root]-[Concentration at coronary sinus or femoral vein]}/ [Concentration at aortic root] х 100. Results: Concentration of βOHB at the aortic root, femoral vein and coronary sinus was significantly higher in patients with CLP (+) than CLP(-) at baseline [129-494 (226) vs 43-236 (105) μmol/L, p=0.0003; 58-412 (131) vs 27-163 (53) μmol/L, p=0.0004; 74-323 (149) vs 26-158 (63) μmol/L, p&lt;0.0001, respectively]. CLP at baseline was related to a decreased coronary βOHB extraction rate [CLP (+): 23.8-33.7% (29.9%) , CLP (-): 33.2-44.0% (38.5%)]. Conclusions: Concentrations of βOHB were elevated in patients with myocaridal ischemia. βOHB extraction rate in the coronary circulation was suppressed by acute and chronic ischemic stresses.

Feasibility analysis on membrane-based right-sided approach of laparoscopic suprapancreatic lymph node dissection for advanced distal gastric cancer

To investigate the feasibility and safety of membrane-based right-sided approach of laparoscopic suprapancreatic lymph node dissection for advanced distal gastric cancer. The clinical data of 41 patients with advanced distal gastric cancer who underwent laparoscopic gastrectomy using membrane-based right-sided approach for laparoscopic suprapancreatic lymph node dissection at the Department of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen University from January 2016 to January 2018 were retrospectively analyzed. There were 24 males and 17 females with a mean age of 56.8 years and a mean body mass index of 22.6 kg/m². Membrane-based right-sided approach of laparoscopic suprapancreatic lymph node dissection contained 4 steps briefly: (1) dissection of mesenteria above the head of pancreas: the tri-junction of pancreas-duodenum was cut to expose and identify the logo of Benz;clearance of the membrane of No.5a was performed towards the left, and then expanded to the posterior layer of No.12a. (2) dissection of the V shape dorsal mesogastrium: membrane bridge at splenic artery trunk root was cut; in suprapancreatic space, clearance was performed towards to the left to the middle of the splenic artery trunk and expanded to the posterior Tolds plane upwards to the posterior phrenic angle and retroperitoneal esophagus, then the surrounding tissue of anterior abdominal aorta. (3) dissection of the U shape mesenteria:membrane bridge at common hepatic artery root was cut; mesentery was separated; the left gastric vein was freed and ligated at its root; in posterior pancreatic space, the mesentery of No.7, No.9 and No.8 was dissected in turns; the left gastric artery was high ligated and cut; the portal vein and posterior dorsal mesogastrium Toldt plane was routinely exposed; clearance was performed to right for No.8a and upward to the hepatic portal meeting at posterior mesentery No.12 plane. (4) dissection of the upper triangular area of pylorus: the trigone mesentery was cut along the upper edge of the pylorus; No.12a was swept upward along the gastric ventral mesentery; the upper boundary(No.8a) on the right side of the U-shaped membrane was joined. Intraoperative and postoperative presentations were analyzed. Laparoscopic gastrectomy for advanced distal gastric cancer with membrane-based right-sided approach of laparoscopic suprapancreatic lymph node dissection was successfully carried out in all the 41 patients. Distal gastric mesenteria en bloc resection was successfully performed. The operation time was (145.2±25.4) minutes and intraoperative blood loss was (53.3±18.3) ml without massive bleeding and severe complication. Number of lymph nodes dissected was 41.1±6.4, and number of suprapancreatic lymph node dissected was 23.3±3.7 without residual cancer at cut margin by pathology. Postoperative drainage volume was (65.8±21.7) ml; time to withdraw of catheter was (7.0±1.7) days; time to fluid intake was (3.5±1.8) days; postoperative hospital stay was (10.4±2.8) days; time to postoperative anal exhaust was (3.3±1.1) days. No complications, such as chyle leakage, postoperative massive bleeding, anastomotic leakage, abdominal cavity infection or gastroplegia occurred within 30 days after surgery. Membrane-based right-sided approach of laparoscopic suprapancreatic lymph node dissection for advanced distal gastric cancer can achieve en bloc resection and conform to the radical principle of oncology, and is safe and feasible.

Toward Improved Cardiac Sparing: Development and Validation of a Hybrid MR/CT Cardiac Segmentation Atlas

Radiation dose to the heart and cardiac substructures has been linked to toxic effects including coronary artery disease and cardiomyopathy. As cardiac substructures are poorly visualized on treatment planning computed tomography (CT), we employed magnetic resonance imaging (MRI)’s superb soft tissue contrast to generate a hybrid MRI/CT atlas, with the ultimate goal of enabling cardiac substructure dose assessment in CT-based planning. A local rigid registration encompassing the heart was performed between the end-expiratory (EE) phase of a non-contrast 4DCT and EE axial T2-weighted MR for a cohort of 11 left breast cancer patients enrolled in an IRB study. Contour delineations using hybrid MR/CT information of 8 patients were made for 13 cardiac substructures namely: heart, right and left atria/ventricles (RA, LA, RV & LV), right (RCA), left main (LM) and left anterior descending (LAD) coronary arteries; ascending aorta (AA), superior/inferior vena cavae (SVC/IVC), and pulmonary artery/veins (PA/PV). Radiation oncologist/Radiologist ground-truth delineations were inputted into an intensity-based deformable registration atlas. Atlas performance was evaluated for 3 test cases via: Dice similarity coefficient (DSC), mean distance to agreement (MDA), centroid displacement, volume percent difference (VPD), and qualitative consensus scoring on a 5-point scale (1 = clinically unacceptable; 2, 3, and 4 = major, moderate, and minor modifications required, respectively; 5 = clinically acceptable). Eight out of 13 contours had a mean DSC >0.6 across 3 test cases, with the heart having the highest DSC (VPD <5%), and the poorest performance in the coronary arteries and pulmonary veins. One-third of all contours had mean VPD <10%. The greatest centroid displacements occurred in the superoinferior direction. Consensus scores for the heart, LV, LA, and AA required minor modifications, typically at the inferior aspects. RA, RV, PA, and SVC/IVC scored between 3-4, requiring moderate modifications. Major modifications were necessary for the PV, RCA, and LAD (scores = 1.7-2) although propagated contours were deemed useful for localization. LM yielded consistent values of 1, suggesting inadequate segmentation.Abstract 1075; TableStructureDSCMDA (mm)Heart0.91 ± 0.012.17 ± 0.14R/L Atria0.77 ± 0.032.73 ± 0.41R/L Ventricles0.73 ± 0.094.18 ± 1.20AA0.72 ± 0.012.72 ± 0.22SVC0.64 ± 0.082.55 ± 0.49IVC0.64 ± 0.104.06 ± 1.97PA0.72 ± 0.062.36 ± 0.67PV0.34 ± 0.014.55 ± 0.75Coronary Arteries (3)0.08 ± 0.076.79 ± 3.30 Open table in a new tab We are the first to demonstrate the application of a hybrid MR/CT atlas for cardiac segmentation, offering strong potential for the assessment of dose to these critical substructures. Atlas performance was clinically acceptable for most substructures. However, further improvement is needed for smaller or more complex structures (e.g., coronary arteries, pulmonary veins) that may require more sophisticated segmentation techniques, such as deep learning.

Three-dimensional surgical simulation of the bile duct and vascular arrangement in pancreatoduodenectomy: A retrospective cohort study.

Background/aimsWe evaluated the usefulness of three-dimensional (3D) images for pancreatoduodenectomy (PD), including the classification of the bile duct and vascular arrangement, i.e., hepatic artery, inferior mesenteric vein (IMV) and left gastric vein (LGV). We evaluated the extent to which this simulation affected the perioperative outcomes of PD.MethodsIn all, 117 patients who underwent PD were divided into the without-3D (n = 53) and with-3D (n = 64) groups, and perioperative outcomes were compared. We evaluated the arrangement of the accessory bile duct and the hepatic artery (type I: the right hepatic artery arising from the superior mesenteric artery, type II: the left hepatic artery arising from the left gastric artery, type III: the most common pattern) and the confluence pattern of the LGV and the IMV [type i: portal vein (PV):splenic vein (SV), type ii: PV:superior mesenteric vein (SMV), type iii: SV:SV, and type iv: SV:SMV] between the two groups.ResultsTwo patients had an accessory bile duct. The 3D images were classified as type I (n = 4), type II (n = 10), type III (n = 48) and other patterns (n = 2); type ii (n = 27) was the most frequent confluence pattern (p < 0.05). Intraoperative blood loss was reduced in the with-3D group (p < 0.05).ConclusionsWe propose that the 3D imaging technique is useful for preoperative assessment in PD.

Impact of portal vein resection with splenic vein reconstruction after pancreatoduodenectomy on sinistral portal hypertension: Who needs reconstruction?

Resection of the porto-mesenterico-splenic confluence is at times necessary during pancreatoduodenectomy with portal vein resection for pancreatic cancer. Although splenic vein ligation can cause sinistral portal hypertension, the incidence of clinically relevant sinistral portal hypertension remains unknown, and the roles of the preservation of potential collateral veins and splenic vein reconstruction are controversial. Patients with pancreatic cancer who underwent pancreatoduodenectomy with porto-mesenterico-splenic confluence resection were assessed for incidence of development of varices by computed tomography at 6 months after pancreatoduodenectomy. We evaluated the risk factors for sinistral portal hypertension and the impact of splenic vein reconstruction on sinistral portal hypertension. Of the 118 patients who underwent pancreatoduodenectomy with porto-mesenterico-splenic confluence resection, 31 (26%) underwent splenic vein reconstruction, 44 patients (37%) developed gastroesophageal varices, and 5 (11%) experienced varix rupture. Sacrifice of all 3 potential collateral veins (what we refer to as the critical veins: left gastric vein, middle colic vein, and superior right colic vein arcade) and absence of any spontaneous splenorenal shunt had a substantial impact on formation of varices. The risk of variceal formation could be stratified based on the number of preserved critical veins, and patent splenic vein reconstruction was associated with a decreased incidence of varices (60% versus 100%, P = .018) among the patients without preservation of the critical veins. In contrast, patients with multiple intact critical veins developed no varices, regardless of splenic vein reconstruction. Sinistral portal hypertension is not uncommon after pancreatoduodenectomy with porto-mesenterico-splenic confluence resection, and the number of preserved critical veins helps to predict the risk of sinistral portal hypertension. Thus, the indication for splenic vein reconstruction should be tailored according to individual risk factors.

Anatomic variations in the left gastric vein and their clinical significance during laparoscopic gastrectomy

Surgeons normally encounter the left gastric vein (LGV) during laparoscopic gastrectomy (LG) for gastric cancer, and the various anatomic variants of this vessel make the procedure difficult. The objective of this study was to classify anatomic variants of the LGV in the laparoscopic operation field and clarify their clinical significance during LG. In total, 405 patients who underwent LG in 2013-2017 for gastric cancer were enrolled in the study. LGV drainage was classified into six types by the anatomic relation of the LGV to the arteries of the celiac axis: Type Ia [LGV runs anteriorly to the common hepatic artery (CHA)], Type Ip (LGV runs posteriorly to CHA), Type II (LGV runs anteriorly to the left gastric artery), Type IIIa [LGV runs anteriorly to the splenic artery (SA)], Type IIIp (LGV runs posteriorly to SA), and Type IV (LGV runs cranially into the proximal portal vein or liver parenchyma). If the LGV was injured during the operation, the patient was included as a member of the injury group (IG). Most patients (n = 391, 96.5%) had a single LGV, whereas 14 (3.5%) patients had double LGVs. Type Ip was the most common of the six drainage types (n = 195, 48.1%). The number of patients in the IG was 49 (13.0%). Types I and III were relatively easily injured when compared with type II (p = 0.025). Patients in the IG had longer operation times, more blood loss, and more lymph node metastases than the non-IG patients. In most patients, the LGV drains posteriorly to the CHA or anteriorly to the LGA. Gastric surgeons should take great care not to injure the LGV during LG when it is not present on the anterior side of the celiac axis.

A multi-site coronary sampling study on CRP in non-STEMI: Novel insights into the inflammatory process in acute coronary syndromes

Background and aimsInflammation has become a key element in cardiovascular disease, and recently, new anti-inflammatory interventions have shown promising results. In this context, CRP levels have been thoroughly studied in vitro and in animals, but studies in humans are scarce and insights into its release, site(s) of production and uptake are not uniform. MethodsWe performed a biomarker study with multi-site sampling in the coronary circulation, in non-ST elevation MI (NSTEMI) patients with coronary angiography and right-sided catheterisation. Trans-lesional gradients were obtained by sampling distal to the culprit lesion, in patients with a suitable anatomy. To asses trans-cardiac gradients, blood was sampled from the systemic circulation, coronary sinus (CS) and great cardiac vein. Concentrations of CRP were measured with a high-sensitivity assay. ResultsIn 42 patients, a median systemic venous CRP concentration of 4.97 mg/L was observed. There was no evidence of a trans-lesional gradient (4.59 mg/L versus 4.56 mg/L, p = 0.278; n = 14). A significant decrease in CRP concentration was observed between systemic arterial and CS samples (4.88 mg/L versus 4.44 mg/L; p < 0.001; n = 42). This trans-cardiac gradient was irrespective of time of presentation, infarct size and culprit lesion location. The gradient was not only driven by blood that ran through the injured myocardium, but also by lower CRP concentrations in the coronary veins that drain non-infarcted myocardium. ConclusionsIn the context of NSTEMI, we observed a trans-cardiac decrease in CRP, which may indicate the first human in vivo proof of a net CRP uptake by the myocardium, with a role for CRP both in the injured and adjacent myocardium.

Coronary Renal Shunt with Splenectomy (CRSS) for Selective Variceal Decompression

Distal splenorenal shunt and coronary caval shunt are commonly used for selective decompression of esophagogastric varices, but they may not solve severe hypersplenism and their application may be hampered by the presence of splenic venous thrombosis or a left gastric vein (LGV) situated deeply behind the pancreas. On the other hand, some patients have an LGV entering the splenic vein (SV). We tried to work out a new selective shunt for this group of patients. Sixteen patients with severe hypersplenism and esophagogastric varices received coronary renal shunt using the SV following splenectomy. After splenectomy, the proximal portion of the SV and the LGV was isolated from the pancreas. The isolated SV was divided at a point 3-5cm left to its junction with the LGV. The proximal orifice was anastomosed to the left renal vein, and the distal orifice was ligated. A clip was applied to the SV for occlusion between the portal vein and LGV. The right gastric and gastroepiploic vessels were divided to block backflow from the portal vein and to reduce the arterial inflow of the varices. No operative mortality or procedure-related complications occurred. Postoperative computed tomography and endoscopy showed that all the shunts were patent and that the varices had been obliterated or markedly alleviated. In the 6-36months' follow-up period, no recurrent variceal hemorrhage or encephalopathy occurred. Coronary renal shunt combined with splenectomy can achieve the goal of selective decompression of esophagogastric varices. It would become an alternative means of selective variceal decompression for patients whose LGV enters the SV.

Coronary-renal shunt combined with splenectomy for selective variceal decompression

Instruction: Selective shuns for gastroesophageal varices including distal splenorenal shunt and coronary-caval shunt may not solve the problems of the giant spleen with serious hypersplenism or deep location of the left gastric vein behind the pancreas. A new selective shunt procedure should be explored. Methods: Coronary-renal shunt combined with splenectomy was performed on 16 patients with gastroesophageal varices and serious hypersplenism due to posthepatitic cirrhosis. The patients had the dilated left gastric vein entering the splenic vein by preoperative CT angiorgraphic evaluation. After splenectomy, the proximal part of the splenic vein with a length of 3-5cm and the left gastric vein were freed from the pancreas. The freed splenic vein was divided at the distal side with the proximal orifice anasomosed to the left renal vein. Ligation or division between sutures was applied to the splenic vein between portal vein and left gastric vein. The right gastric and gastro-epiploic vessiles were divided to occlude the back flow from the portal vein. Results: There were no operative motality and no procedure-relative complications. Post-operative CT and endoscopy showed the shunts were patent with reduced or obliterative varices in all sixteen patients. There were no recurrent variceal haemorrhage nor encephalopathy by 6-36 months' follow-up. Conclusion: This procedure can reach the aim of selective variceal decompression when splenectomy is required. Keywords: portal hypertension; coronary-renal shunt; selective variceal decompression; splenectomy

Is ventricular sensing always right, when it is left?

Ventricular sensing in transvenous cardiac implantable electronic devices (CIEDs) occurs conventionally from the right ventricular (RV) channel, though it evolved from epicardial sensing both in pacemakers and implantable cardioverter-defibrillators (ICDs). The objective of this study was to observe the reliability of left ventricular (LV) sensing by transvenous leads placed in coronary veins. LV leads were used for sensing and arrhythmia detection in clinical situations where placement of an RV lead across the tricuspid valve was either not preferred or not feasible, or RV signal was unsuitable for arrhythmia detection, or in the event of sensing failure of an RV lead under advisory in cardiac resynchronization therapy defibrillator (CRTD) recipients. Thirty-seven patients had an IS-1 LV lead connected to the RV port of CIEDs (17 pacemakers, 5 cardiac resynchronization therapy pacemaker [CRTP], 2 ICDs, and 13 CRTDs). Along a median 41 (25-67) months follow-up, lead performance remained stable; there were neither undersensing nor oversensing of non-cardiac signals. VT/VF were correctly detected and terminated by ATP and shocks (one and three patients, respectively); no inappropriate arrhythmia detection. Device reprogramming occurred in four CRTD recipients because of transient counting the QRS (short intervals) when paced in LV-only, and in two with T-wave oversensing. Ventricular sensing by an LV lead is feasible in transvenous devices. Sensing programmability is an unmet need: to fix RV lead sensing issues in cardiac resynchronization therapy (CRT) recipients at no risk of infection (no pocket opening); to avoid interaction with the tricuspid valve; to avoid lead redundancy in the vasculature. Moreover, it will be mandatory owing to the loss of lead interchangeability due to the adoption of DF-4 and quadripolar leads.

VS03.01: QUANTITATIVE IMAGING OF CHANGE IN MICROCIRCULATION BY SIDESTREAM DARK FIELD MICROSCOPY (SDF) AFTER ESOPHAGECTOMY

Abstract Description Anastomotic leakage is one of the most severe complications after esophageal resection with gastric tube reconstruction. Impaired perfusion of the gastric fundus is seen as the main contributing factor for this complication. Transection of the left gastric and gastro-epiploic artery and veins results in compromised perfusion in the fundus area which can result in anastomotic dehiscence (5–20%), relating to high morbidity and mortality (3–4%). The main objective of this observational study is to evaluation gastric tube microcirculation with Sidestream Darkfield Microscopy (SDF). Method This study included 22 patients (October 2015 - June 2016). Intra-operative microscopic images of gastric tube microcirculation were obtained with SDF directly after reconstruction. Using software (AVA2.0), the following parameters were evaluated: average velocity (μm/sec), Microvascular Flow Index (MFI), Total Vessel Density (TVD), Perfusion Vessel Density (PVD), Proportion of Perfused Vessels (PPV) and the De Backer Score (DBS), to assess change in perfusion. Results SDF accurately visualized and evaluated microcirculation in all patients. A SDF-stabilizer was used to create stable images. The average velocity decreased significantly towards the fundus (P = 0.001). Also, MFI, PVD and PPV were significantly lower towards the fundus, compared to the base of the gastric tube (P = 0.0002). No differences in TVD and DBS were observed, which was associated to the observed vessel dilation in the fundus-area. This vessel dilation proposes that compromised venous return may play an important role in the development of necrosis and leakage. Three patients developed anastomotic leakage. Conclusion This is the first study presenting quantitative microcirculation imaging with SDF of the gastric tube. Velocity, MFI, TVD and PPV were accurate parameters to observe change in perfusion after reconstruction. Also, vessel dilation in the fundus suggests a role for venous return in the development of ischemia. Quantitative microcirculation with SDF could allow for intra-operative early risk stratification, and, potentially, can result in a reduction of anastomotic leakage. Disclosure All authors have declared no conflicts of interest.

PS01.080: A CASE REPORT OF JEJUNAL VARICEAL BLEEDING SUCCESSFULLY TREATED WITH PERCUTANEOUS TRANSHEPATIC OBLITERATION AFTER SURGERY OF ESOPHAGOGASTRIC JUNCTIONAL CARCINOMA

Abstract Background Varicose veins in the esophagogastric junction rarely occur after surgery of esophagogastric junctional carcinoma, because the collateral pathway of the left gastric vein and short gastric vein was sacrificed. We presented a case of jejunal variceal bleeding successfully treated with percutaneous transhepatic obliteration after surgery of esophagogastric junctional carcinoma. Methods Case report. Results A 50-year-old man with alcoholic liver cirrhosis (Child-B) was admitted for abdominal pain, three months after proximal gastrectomy for esophagogastric junctional carcinoma. After diagnosed with peritonitis due to jejunal perforation, emergency surgery was performed. The next day after surgery, he had developed a lot of black stool. Gastroduodenoscopy revealed the variceal bleeding at the anal side of the esophagojejunal anastomois. Although endoscopic clipping was performed, intermittent bleeding was observed for several days. Since the contrast-enhanced computed tomography scanning revealed jejunal vein dilation at the anal side of the esophagojejunal anastomois, we planned to perform percutaneous transhepatic obliteration. Percutaneous transhepatic portography revealed jejunal varices and drained to the inferior vena cava, and continuously obliterated by 5% EOI (Ethanolamine oleate iopamidol). He was discharged without re-bleeding on the 14th day after the obliteration. Conclusion Percutaneous transhepatic obliteration might be a useful treatment option for jejunal variceal bleeding after surgery of esophagogastric junctional carcinoma. Disclosure All authors have declared no conflicts of interest.

Lymphadenectomy in supra-pancreatic area during laparoscopy-assisted D2 radical distal gastrectomy

Laparoscopy-assisted D2 radical distal gastrectomy has been acknowledged as standard procedure for local advanced gastric cancer. But due to the abundant blood vessels and complicated anatomy of the stomach, lymphadenectomy has been considered as one of the difficulties of the operation, especially in the supra-pancreatic area. This article is to share the experiences of this topic from Department of Gastrointestinal Oncology Surgery, The First Affiliated Hospital of Xiamen University with the following five aspects. (1) How to dissect No.11p lymph nodes thoroughly and whether the exposure of splenic vein is needed? (2) Is it necessary to reveal portal vein during the lymphadenectomy of supra-pylorus and supra-pancreatic areas?(3) During laparoscopic operation, where is the posterior boundary of No.9 lymph nodes at the right side of celiac artery?(4) How to make it easier, safer, and more complete for supra-pancreatic lymphadenectomy? (5) How to deal with the tandem enlarged lymph nodes at the right side of celiac artery? According to the authors' experiences of laparoscopic radical gastrectomy, the following points may be helpful to make the supra-pancreatic lymphadenectomy safe, complete, and standard: (1) Transection of vessels of duodenum, right stomach and left stomach in advance will make the lymphadenectomy at the right side of the celiac artery easier. (2) The exposure of splenic vein as far as possible is necessary during the dissection of No.11p lymph nodes, and it is necessary to dissect the lymph-adipose tissue at the posterior-superior border of splenic artery and pancreas in front of Gerota fascia. (3) The left side of portal vein must be revealed initiatively for dissection of No.12a lymph nodes. (4) The lymph-adipose tissue must be dissected at the included angle of common hepatic artery and celiac artery and the right wall of the celiac artery should be revealed during the dissection of No.8a and the right side of No.9 lymph nodes. (5) The exposure of portal vein and the transection of left gastric vein at the root will make the dissection of this area safer and complete. (6) En bloc D2 plus operation will be a better option, when comfronted with tandem enlarged lymph nodes at the right side of celiac artery.

Coronary sinus mapping of the optimal LV electrode position

Cardiac resynchronization therapy (CRT) is an established pillar of treatment for patients with chronic heart failure. However, 30% of patients do not respond adequately to this type of therapy. One possible reason for this is anonoptimal left ventricular stimulation site. This review focuses on possibilities of visualization of the coronary vein anatomy and its role in the determination of the electrical and mechanical dyssynchrony to optimize the therapeutic success of the resynchronization therapy. In addition, the clinical implication and the perspectives of adedicated mapping of the coronary vein are discussed. Finally, abrief outlook on current and future technologies for improving this form of therapy is given.

Abstract 251: The Role of Adenosine Derived From Mesenchymal Stromal Cell on Neutrophil Extracellular Trap Formation in Myocardial Ischemia Reperfusion

Introduction: In response to tissue damage or infection, neutrophils expel their chromatin into the extracellular space in a thrombotic and inflammatory process called neutrophil extracellular traps(NETs). There is increasing evidence that NETs play a role in myocardial ischemia/reperfusion (MI/R) injury. NETs are found in thrombi aspirated from coronary arteries, atherosclerotic plaques, and deep vein thrombosis. However, nothing is known about the regulation of NETs in vivo. We hypothesized that adenosine, well know for anti-inflammatory effects, reduces NET formation. After MI/R, adenosine is made from conversion of ATP released from damaged cells. Methods: Neutrophils were isolated from human venous blood and stimulated to produce NETs by PMA, a PKC agonist and is well known to induce robust NET formation and serves as a positive control. NETs were quantified by Sytox green fluorescent to quantify extracellular DNA and immunohistochemical staining for citrullinated histone H3, a specific marker of NETs. Results: Neutrophils treated with PMA increased NET production (1.81fold vs unstimulate groups, p&lt;0.001, n=27-28). Neutrophils treated with adenosine (10uM) had a 30.2% decrease NET formation (p&lt;0.001, n=15). There are four adenosine receptors called A1, A2a, A2b, and A3. We used agonists and antagonists’ strategy to check probable receptors involved in suppression NETs signal. We find both A2a receptor agonist-CGS 21680 and A2b agonist-BAY 60-6583 can suppress NETs formation (29.6% and 29.3% respectively p&lt;0.001, n=5-6). But only A2a antagonist-ZM241385 can reverse adenosine’s inhibition (13.8%v.s.24.7%, p&lt;0.05, n=6). Conclusion: Adenosine can downregulate NET formation in vitro likely through A2a receptor activation. Future studies will investigate A2a receptor using genetic knock out, as well as in vivo significance of NET inhibition in MI/R.

Casein kinase-2 (CK2) inhibition by TBCA attenuates VSMC and fibroblast proliferation without adverse effects on endothelial cell behaviour or inflammation

Aim: Intimal thickening within human saphenous vein (HSV) grafts leads to unacceptably high failure rates of coronary artery vein grafts. Treatments to reduce intimal thickening need to attenuate vascular smooth muscle cell (VSMC) and fibroblast proliferation without detrimental effects on endothelial cells (ECs). In this study we compared the effect of four CK2 inhibitors on VSMC, fibroblast and EC behaviour to determine their potential use in retarding intimal thickening.

P2879Recurrence of atrial fibrillation after catheter ablation is associated with fibrotic marker in coronary sinus vein and left atrium pressure

P2879Recurrence of atrial fibrillation after catheter ablation is associated with fibrotic marker in coronary sinus vein and left atrium pressure

Visualisation of coronary venous anatomy by computed tomography angiography prior to cardiac resynchronisation therapy implantation.

BackgroundThe purpose of this study was to illustrate the additive value of computed tomography angiography (CTA) for visualisation of the coronary venous anatomy prior to cardiac resynchronisation therapy (CRT) implantation.MethodsEighteen patients planned for CRT implantation were prospectively included. A specific CTA protocol designed for visualisation of the coronary veins was carried out on a third-generation dual-source CT platform. Coronary veins were semi-automatically segmented to construct a 3D model. CTA-derived coronary venous anatomy was compared with intra-procedural fluoroscopic angiography (FA) in right and left anterior oblique views.ResultsCoronary venous CTA was successfully performed in all 18 patients. CRT implantation and FA were performed in 15 patients. A total of 62 veins were visualised; the number of veins per patient was 3.8 (range: 2–5). Eighty-five per cent (53/62) of the veins were visualised on both CTA and FA, while 10% (6/62) were visualised on CTA only, and 5% (3/62) on FA only. Twenty-two veins were present on the lateral or inferolateral wall; of these, 95% (21/22) were visualised by CTA. A left-sided implantation was performed in 13 patients, while a right-sided implantation was performed in the remaining 2 patients because of a persistent left-sided superior vena cava with no left innominate vein on CTA.ConclusionImaging of the coronary veins by CTA using a designated protocol is technically feasible and facilitates the CRT implantation approach, potentially improving the outcome.Electronic supplementary materialThe online version of this article (10.1007/s12471-018-1132-2) contains supplementary material, which is available to authorized users.