Dissection Of Vessels Research Articles

#1694 The Cl-/HCO3-ratio as a predictor of decompensated metabolic acidosis in CKD stages G4 and G5

Abstract Background and Aims Metabolic acidosis (MA) is a common disorder in patients with chronic kidney disease (CKD) and is associated with both a normal anion gap (AGMA) and a high anion gap (HAGMA). AGMA is typically detected early in the course of CKD, whereas HAGMA appears later in the course of CKD due to the accumulation of non-chloride anions such as phosphate, sulphate, and an array of organic acids. The anion gap (AG) is usually calculated as the difference between serum concentration of cations and anions using the formula AG=Na+-(Cl−+HCO3−). The most important anions in serum are chlorides (Cl−) and bicarbonates (HCO3−). The more advanced the CKD, the higher the AG. As eGFR decreases, a reciprocal decrease in HCO3− and an increase in chloride concentration is observed to correct the AG. The aim of this study is to determine whether the Cl−/HCO3− ratio can be used to predict decompensated metabolic acidosis with pH decline in CKD stages G4 and G5. Method A total of 115 patients (median age 63 ± 17 years), with CKD stage G4 or G5 were enrolled in this cross-sectional study. Demographic and comorbidity data was obtained from medical records, and the Charlson Comorbid Index (CCI) was calculated. A two-year clinical follow-up was conducted to assess the clinical status of each patient. The number of patients, the time dialysis was started, and deaths were all recorded. All patients were qualified for arteriovenous fistula creation in predialysis period. The arterial (A) and venous (V) blood samples were taken during surgery, directly after vessel dissection, and evaluated in a point of care testing analyzer (POCT). The ratio of arterial Cl− and HCO3− concentration were calculated. According to mean arterial pH (pH-A) the group was divided into Group A pH-A<7.33 and Group B pH-A≥7.33 (Table 1). Results In Group A was significantly lower pH-A, pH-V, HCO3−-A, HCO3−-V, pCO2-A, pCO2-V, and significantly higher both arterial and venous Cl− and the Cl−/HCO3− ratios compared to Group B. No such differences were observed in the case of AG. Cl−/HCO3−-A ratio negatively correlated with pH (r = −0.77, p < 0.01) (Fig. 1A). The discriminative power of Cl−/HCO3−-A ratio for predicting pH-A≤7.33 was 0.917 (95% confidence interval [CI] = 0.87–0.97; p < 0.01) which provided 87% sensitivity and 84% specificity (Fig. 1B). The best cut-off was 6.22 (mmol/l)/(mmol/l). Conclusion The Cl−/HCO3− ratio lower than 6.22 (mmol/l)/(mmol/l) may be used as predictor of decompensated metabolic acidosis.

Extracranial-Intracranial Microsurgical Bypass Using a Y-Shaped Vein Graft From the Hand

While extracranial-intracranial (EC-IC) bypass is commonly performed by neurosurgeons with specific expertise in cerebrovascular surgery, they can also be performed together with microvascular plastic surgeons. At our institution, some EC-IC bypass cases have evolved to be performed by neurosurgeons and plastic surgeons in a combined approach. Given the plastic surgeons’ expertise and volume of experience in performing microvascular surgery, their skills are utilized in performing the donor vessel dissection as well as the bypass itself. This paper outlines a Canadian perspective on collaboration between plastic surgeons and neurosurgeons in performing EC-IC bypass along with a case report illustrating the use of a dorsal hand Y-shaped vein graft for EC-IC bypass, which has not been described in the literature to date.

Tongue patch angioplasty for small-caliber vein segments directly connected to juxta-anastomotic stenosis.

This study introduces a surgical method to increase the size of small vessels in patients with juxta-anastomosis stenosis (JAS) requiring full-length dissection. The small-caliber segment that is adjacent to JAS is usually expanded using balloon angioplasty or surgically resected. After resection, if the cannulation site is sufficient, only the arterial anastomosis is moved proximally; otherwise, it is replaced with a prosthetic graft. Herein, we describe the cases of two 60- and 34-year-old men with left brachio-basilar and left radiocephalic fistulas, respectively. The first and second patients needed transposition and superficialization, respectively, both of which required full-length vessel dissection. Both patients developed JAS with a long, small-caliber segment, leaving no space for arterial needle cannulation. A tongue patch with a graft on the bottom and a native vein on the top was used to resolve the JAS and make the native vein the needle cannulation site. In our cases, this method was effective for more than 2 years without adverse events in the particular surgical area. Although this method had a complicated indication, it could help ensure a sufficiently long area of the native vein for cannulation.

Bailout Distal Internal Carotid Artery Stenting after Carotid Endarterectomy: Indications, Technique, and Outcomes

Distal internal carotid artery (ICA) stenting may be employed as a bailout maneuver when an inadequate end point or clamp injury is encountered at the time of carotid endarterectomy (CEA) in a surgically inaccessible region of the distal ICA. We sought to characterize the indications, technique, and outcomes for this infrequently encountered clinical scenario. We performed a retrospective review of all patients who underwent distal ICA stenting at the time of CEA at our institution between September 2008 and July 2022. Procedural details and postoperative follow-up were reviewed for each patient. Six patients were identified during the study period. All were male with an age range of 63 to 82years. Five underwent carotid revascularization for asymptomatic carotid artery stenosis, and one patient was treated for amaurosis fugax. Three patients were on dual antiplatelet therapy preoperatively, whereas 2 were on aspirin monotherapy, and one was on aspirin and low-dose rivaroxaban. Five patients underwent CEA with patch angioplasty, and one underwent eversion CEA. The indication for stenting was distal ICA dissection due to clamp or shunt injury in 2 patients and an inadequate distal ICA end point in 4 patients. In all cases, access for stenting was obtained under direct visualization within the common carotid artery, and a standard carotid stent was deployed with its proximal aspect landing within the endarterectomized site. Embolic protection was typically achieved via proximal common carotid artery and external carotid artery clamping for flow arrest with aspiration of debris before restoration of antegrade flow. There was 100% technical success. Postoperatively, 2 patients were found to have a cranial nerve injury, likely occurring due to the need for high ICA exposure. Median length of stay was 2days (range 1-7days) with no instances of perioperative stroke or myocardial infarction. All patients were discharged on dual antiplatelet therapy with no further occurrence of stroke, carotid restenosis, or reintervention through a median follow-up of 17months. Distal ICA stenting is a useful adjunct in the setting of CEA complicated by inadequate end point or vessel dissection in a surgically inaccessible region of the ICA and can minimize the need for high-risk extensive distal dissection of the ICA in this situation.

Enhancing the Microneurosurgical Training: Development of the Folded Placenta Model for Simulation of the Deep Operative Field Challenges of Cranial Procedures

Neurosurgery relies heavily on advanced manual skills, necessitating effective training models for skill development. While various models have been utilized, the human placenta has emerged as a promising candidate for microneurosurgical training due to its anatomical similarities with cerebral vasculature. However, existing placenta models have primarily focused on simulating superficial procedures, often neglecting the complexities encountered in deep operative fields during cranial surgeries. This study obtained ethical approval and implemented a modified placenta model to address the limitations of existing training models. The key modification involved folding the placenta and placing it within a rigid container, closely mimicking the structural challenges of cranial procedures. The placenta preparation followed a standardized protocol, including the use of specialized equipment for documentation. The primary feature of the modified model is the folded placenta within the rigid container, which replicates cranial anatomy. This innovative approach enables trainees to engage in a comprehensive range of microsurgical exercises, encompassing vessel dissection, aneurysm clipping, tumor resection, and more. The model successfully mirrors the complexities of real cranial procedures, providing a realistic training experience. The presented modified placenta model serves as an effective tool for simulating the conditions encountered in deep cranial surgeries. By accurately replicating the challenges of deep operative fields, the model significantly enhances the training of neurosurgical residents. It successfully prepares trainees to navigate the intricacies and difficulties inherent in real cranial surgeries, thus contributing to improved surgical skills and readiness for neurosurgical practice.

Simultaneous multiple cervical vessel dissection manifested as pulsatile tinnitus.

A previously healthy 43-year-old woman with Wallenberg syndrome, stemming from a left vertebral artery dissection and resulting in a left lateral medulla oblongata infarct, was later diagnosed with simultaneous bi-carotid and right V3 dissection. Seven days post-admission, she experienced sudden right-sided pulsatile tinnitus and exhibited a right-sided carotid murmur. High-resolution vessel wall MR imaging confirmed the new dissections. While spontaneous cervical vessel dissections involving more than two arteries are rare (less than 2% of cases), the prognosis is generally favorable. This case is noteworthy for presenting pulsatile tinnitus as a rare post-stroke dissection recurrence symptom, as documented in medical literature.

Microsurgical Practice with Use of Smartphone Camera as the Microscopic Field.

Accessibility of microsurgical equipment is a major barrier to proper training of surgeons before live patient free flap surgery. A technique is presented that uses a smartphone camera as the microscopic field, eliminating the need for an expensive operative microscope for surgical practice. A convenient and cost-effective simulation protocol could reduce the time frame of the microsurgery learning curve. Furthermore, the use of the smartphone video function may allow improved feedback by mentors, improving access and communication between microsurgical teachers and learners. The PocketSuture smartphone stand is a commercially available device that allows the smartphone camera to be used as magnification. The proposed education protocol included suture practice, vessel dissection, and free tissue transfer in nonliving animal models, with vessel anastomosis and patency confirmation performed with a smartphone camera for field magnification. Video of the suturing technique allowed feedback from the mentor. A progressive suturing protocol leading to the ability to perform microsurgical anastomosis on nonliving animal models was developed. The basic costs for the stand, instrument set and suture were less than $500. The PocketSuture smartphone stand can be used for microsurgical training with real-time video for plastic surgery learners with limited access to microscopes and local mentors.

Surgical techniques for robotic right donor hepatectomy, part 1: robotic hilar dissection and right lobe mobilization.

Robotic surgery is emerging as a feasible minimally invasive approach for donor hepatectomy at specialized centers. The aim of this article is to systematically describe the surgical techniques for robotic hilar dissection and right lobe mobilization in right donor hepatectomy. The setup of the robotic arms, the dissection of inflow vessels and retrohepatic inferior vena cava, and the pearls and pitfalls of these two parts of the operation are detailed.

Training for endovascular therapy of acute arterial disease and procedure-related complication: An extracorporeally-perfused human cadaver model study.

The aim of this study was to evaluate the usability of a recently developed extracorporeally-perfused cadaver model for training the angiographic management of acute arterial diseases and periprocedural complications that may occur during endovascular therapy of the lower extremity arterial runoff. Continuous extracorporeal perfusion was established in three fresh-frozen body donors via inguinal and infragenicular access. Using digital subtraction angiography for guidance, both arterial embolization (e.g., embolization using coils, vascular plugs, particles, and liquid embolic agents) and endovascular recanalization procedures (e.g., manual aspiration or balloon-assisted embolectomy) as well as various embolism protection devices were tested. Furthermore, the management of complications during percutaneous transluminal angioplasty, such as vessel dissection and rupture, were exercised by implantation of endovascular dissection repair system or covered stents. Interventions were performed by two board-certified interventional radiologists and one resident with only limited angiographic experience. Stable extracorporeal perfusion was successfully established on both thighs of all three body donors. Digital subtraction angiography could be performed reliably and resulted in realistic artery depiction. The model allowed for repeatable training of endovascular recanalization and arterial embolization procedures with typical tactile feedback in a controlled environment. Furthermore, the handling of more complex angiographic devices could be exercised. Whereas procedural success was be ascertained for most endovascular interventions, thrombectomies procedures were not feasible in some cases due to the lack of inherent coagulation. The presented perfusion model is suitable for practicing time-critical endovascular interventions in the lower extremity runoff under realistic but controlled conditions.

The Current Status of Endovascular Treatment for Extracranial Vertebral Artery Stenosis in Japan: A Subanalysis of the Japanese Registry of Neuroendovascular Therapy 4.

Endovascular treatment (EVT) is a potential therapeutic option for extracranial vertebral artery (VA) stenosis; however, its efficacy or optimal procedures remain unknown. This study aimed to investigate the recent status of EVT for extracranial VA stenosis in Japan using a nationwide registry. We conducted a post hoc analysis of the Japanese Registry of Neuroendovascular Therapy 4 that enrolled patients who underwent EVT at 166 hospitals in Japan from 2015 to 2019. The outcomes of this study were as follows: procedural success indicating that the planned procedure was completed, modified Rankin Scale (mRS) score at 30 days, and procedure-related complications evaluated according to the procedure during EVT (percutaneous transluminal angioplasty vs. stenting and with or without the use of embolic protection devices [EPDs]). Of 308 eligible patients, 301 (95%) were treated for atherosclerotic stenosis, predominantly by stenting (74%). EPDs were used in 43%, primarily with the distal balloon (63%). The proportion of procedural success was 98%. Functional independence (mRS of 0-2) at 30 days was achieved in 80% of the total cohort, and there were no differences between patients treated with or without stenting or EPDs (74% vs. 82%, p = 0.12, and 80% vs. 80%, p = 0.93). Procedural complications occurred in 28 (9.1%) patients similarly in each group, with distal embolism and vessel dissection being common. In conclusion, EVT is a reasonable option for extracranial VA stenosis as a daily clinical practice. This study emphasizes the potential of EVT in managing extracranial VA stenosis and the need for further research to refine treatment strategies.

Safety and efficacy of endovascular thrombectomy for primary and secondary MeVO

BackgroundMedium-vessel occlusions (MeVO) are emerging as a new target for endovascular treatment (EVT). Primary MeVO occur de novo, while secondary MeVO arise from large vessel occlusion (LVO) through clot migration or fragmentation - spontaneously, following intravenous thrombolysis or EVT. We aimed to evaluate efficacy and safety of EVT in primary and EVT-induced secondary MeVO. MethodsRetrospective single-center study on consecutive EVT-treated acute ischemic stroke, from 2019-to-2021. We considered: (1) exclusive-LVO, patients with LVO and – in case of residual distal occlusion – no rescue endovascular procedure; (2) primary MeVO: initial A2, A3, M2 non-dominant, M3, P2, P3 occlusions; (3) EVT-induced secondary MeVO, presenting LVO with subsequent (treated) EVT-induced MeVO. We compared (univariable/multivariable logistic regression) EVT efficacy (eTICI≥2b, 3-month modified Rankin Scale [mRS] 0-2) and safety (EVT-complications [vessel dissection, perforation, persistent-SAH], symptomatic ICH) in all MeVO versus exclusive-LVO, primary MeVO versus exclusive-LVO, EVT-induced secondary MeVO versus exclusive-LVO and EVT-induced secondary MeVO versus primary MeVO. ResultsWe included 335 patients: 221 (66.0 %) exclusive-LVO and 114 (34.0 %) MeVO (55 [48.2 %] primary, 59 [51.8 %] secondary). Compared to exclusive-LVO, primary MeVO had higher rates of EVT complications (aOR 3.77 [95%CI 1.58-9.00],p=0.003), lower rates of eTICI≥2b (aOR 0.32 [95%CI 0.12-0.88],p=0.027) and mRS 0-2 (aOR 0.28 [95%CI 0.13-0.63],p=0.002). EVT-induced secondary MeVO had no major differences in efficacy and safety outcomes compared to exclusive-LVO, but a better mRS 0-2 (aOR 8.00 [95%CI 2.12-30.17],p=0.002) compared to primary MeVO. ConclusionsPrimary and EVT-induced secondary MeVO showed different safety/efficacy EVT-related profiles. Dedicated randomized data are needed to identify the best acute reperfusion strategy in the two categories.

Robot-assisted right wedge-shaped sleeve lower bilobectomy with knotless suture anastomosis: a case report

BackgroundIn bronchoplasty of wedge resections, it is necessary to transect the bronchus at a sharp angle and depth. As a result, anastomoses after wedge resections have the disadvantages of poor visibility and operability. Here, we report a case of right wedge-shaped sleeve bilobectomy that was successfully performed with continuous knotless suturing using robotic assistance.Case presentationAn 81-year-old male patient was referred for the treatment of a tumor in the right lower lobe, which protruded into the bronchus intermedius. The tumor was diagnosed as squamous cell carcinoma by transbronchial biopsy, cT1cN1M0 stage IIB carcinoma for which surgery was indicated. Because the pulmonary middle lobe artery was involved and a resection margin from the tumor protruding into the bronchial mucosal epithelium was necessary, a right wedge-shaped sleeve bilobectomy was performed. The bronchial anastomosis was performed with robotic assistance. After dissection of pulmonary vessels and interlobes, the upper lobe bronchial bifurcation was transected in a wedged shape, and a lower bilobectomy was performed. The bronchi were sutured continuously with knotless sutures. A continuous suture was performed from the ventral to the caudal side. After suturing to the dorsal side, another continuous suturing was performed from the cranial side. Continuous sutures were made until each thread passed through the other. Pericardial fat was wrapped around the anastomosis.ConclusionsA better visual field could be obtained owing to robot-assisted surgery, and robotic arms enabled an accurate and safe operation. Furthermore, continuous suturing using a knotless suture made it easier for the sutures to be handled and enabled bronchial anastomosis without assistance.

A comparative study of robot-assisted thoracoscopic surgery and conventional approaches for short-term outcomes of anatomical segmentectomy

ObjectivesSince anatomical segmentectomy requires meticulous dissection of the segmental pulmonary vessels and bronchus, robot-assisted thoracoscopic surgery (RATS) has been widely adopted in recent years. We investigated the usefulness of RATS segmentectomy by comparing perioperative outcomes with conventional approaches including open thoracotomy or video-assisted thoracoscopic surgery (VATS). We compared perioperative outcomes of segmentectomy between RATS and conventional approaches including open thoracotomy or video-assisted thoracoscopic surgery (VATS).MethodsThis single-institutional retrospective study comprised 231 patients with primary lung cancer who underwent segmentectomy by RATS or conventional approaches between January 2011 and December 2022. Surgical outcomes and postoperative complications were analyzed among patients whose background factors were adjusted by propensity score matching (PSM).ResultsBefore PSM, there were significant differences in age, smoking status, and types of segmentectomy. After PSM, 126 patients (63 patients in each group) were included in this analysis. The RATS group had significantly shorter operative time (154 vs 210 min; p < 0.01), fewer bleeding amounts (10 vs 40 mL; p < 0.01), and shorter duration of chest drainage (2 vs 2 days; p = 0.04) than the conventional-approach group. There was no significant difference in the incidence of all complications; however, the incidence of postoperative pneumonia was significantly lower than in the conventional-approach group (p = 0.02).ConclusionsRATS segmentectomy is proposed to be useful. It was suggested that RATS segmentectomy may be useful with better perioperative results than the conventional approach. Further studies on oncological long-term outcomes and cost–benefit comparisons are needed.

Abstract 043: Intra‐cranial Rescue stenting in patients with incomplete perfusion following mechanical thrombectomy;a systemic review and meta‐analysis.

Introduction Incomplete reperfusion following Mechanical Thrombectomy (MT) ranges from 12–34% and patients with Intracranial atherosclerotic (ICAS) occlusions are disproportionally affected.(1, 2)These patients are also more likely to experience poor functional outcomes. (3) Rescue stenting (RS) in these patients has shown promising rates of recanalization and better outcomes in preliminary studies. In our systemic review and meta‐analysis, we included Sixteen dual arm and seven single arm studies in order to study recanalization rate and compare outcomes following rescue stenting in patients with incomplete reperfusion compared to those managed conservatively (no‐RS).(4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19)(20, 21, 22, 23, 24, 25, 26) Methods Our study was performed according to the preferred reporting items for systematic review and meta‐analysis (PRISMA) guidelines.(27) We incorporated studies that included participants, aged 18 years or older, and met the following criteria: (1) participants with ischemic stroke with Intracranial Atherosclerotic Stenosis (ICAS) who underwent at least one attempt of MT and had incomplete perfusion after the procedure (2) participants who received rescue stenting after MT with incomplete reperfusion, with no restrictions on the type of stents or stenting procedure used; (3) both observational studies (case series, cohort studies) and experimental designs (randomized controlled trials) were considered; (4) the control group consisted of patients incomplete reperfusion following MT but did not received no rescue stenting and were conservatively managed. We reported the recanalization rate in patients undergoing MT and compared the outcomes between the RS and no‐RS groups; MRS ≤ 2 at 90 days, Mortality at 90 days, Symptomatic Intra cranial Hemorrhage (sICH), Any Intracranial Hemorrhage (ICH), vessel dissection and vessel perforation Results Patients who underwent stenting experienced recanalization rate of 84% (95% CI: 79.0 – 88.1). They also had significantly higher odds of a better functional outcome (MRS ≤ 2 at 90 days) at 3 months compared to the no‐RS group (OR 2.70 [95% CI: 1.89 ‐ 3.86]). Odds of sICH (OR 0.92 [95% CI: 0.62 ‐ 1.36]) and any ICH (OR: 0.64 [95% CI 0.40 ‐ 1.03]) were lower but insignificant in the RS group. Odds of mortality at 90 days were significantly lower in the RS group(OR 0.59 [95% CI: 0.42 ‐ 0.83]). No significant difference in Odds of Vessel dissection (OR 1.22 [95% CI: 0.19 ‐ 8.07]) or vessel perforation (OR 0.40 [ 95% CI: 0.10 ‐ 1.61]) between the two groups was noted. Conclusion Out meta‐analysis which included the most recent studies indicates that rescue setting after mechanical thrombectomy for large artery intracranial atherosclerosis with incomplete perfusion or with residual stenosis (&gt;50 percent) is associated with better clinical outcomes and indicates lower mortality rate and associated complications. Therefore, rescue stenting can be considered as a safe and viable option in these patients.

Distal pancreatectomy with partial preservation of the spleen: a new surgical technique.

Presently, spleen-preserving distal pancreatectomy is predominantly utilized for benign or low-grade malignant tumors of the pancreatic body and tail. The splenic blood vessel-preserving Kimura technique and non-splenic blood vessel-preserving Warshaw technique represent the two primary procedures. In prior reports, total splenectomy was most frequently performed when splenic blood vessels could not be preserved, and severe splenic congestion and ischemia were identified following the dissection of splenic blood vessels. This paper introduces a new method of spleen-preserving distal pancreatectomy, entailing a distal pancreatectomy with partial spleen preservation, illustrated through the presentation of two surgical cases. During physical examination, two patients were identified to have benign or low-grade malignant masses in the pancreatic tail. Preoperative examination indicated that the lesion was closely associated with the splenic blood vessels or splenic hilum. During surgery, neither the Kimura technique nor the Warshaw technique could be executed. After resecting the pancreatic body and tail, and a portion of the spleen, the superior pole of the spleen was successfully preserved by maintaining the short gastric blood vessels therein. This technical report demonstrates the viability of this novel spleen-preserving distal pancreatectomy, a distal pancreatectomy with partial spleen preservation, for benign and low-grade malignant pancreatic body and tail lesions. The innovative technique achieves partial spleen preservation by effectively preserving the short gastric blood vessels in the superior pole of the spleen.

Abstract 139: Super Distal Access using the Vecta46 Intermediate Catheter in Embolization of the MMA for cSDH

Introduction There is increasing literature to support the efficacy of middle meningeal artery (MMA) embolization in the treatment of chronic subdural hematomas (cSDH). Techniques for optimal embolization of the MMA are yet to be elucidated. We hypothesized utilization of a novel 046” intermediate catheter within the proximal MMA trunk carry procedural advantages for multiple pedicle embolizations and ease of navigation to distal MMA vasculature. Methods We retrospectively reviewed and analyzed a prospectively maintained IRB‐approved database of the senior authors. Results Twenty‐one (21) consecutive cases of Vecta46 utilization with MMA embolization were identified (2023), in patients 69±13 years (range 49‐83 years), 4 (19%) women. Four (19%) patients were on antiplatelet/anticoagulants. At presentation, recurrent cSDH in 9 patients (43%) were previously managed with burr holes (n=2, 22%), craniotomy (n=3, 33%), or without drainage (n=4, 44%). Average admission cSDH thickness was 8.8±1.6mm, midline shift of 3±0.7mm. Access was performed through a 5‐ or 6‐French arteriotomy. Both anterior and posterior MMA branches were embolized in 16 (76%) cases, and adjunctive coiling of the proximal MMA trunk was performed in all cases. Vecta46 was successfully placed in the proximal MMA trunk in all cases. There were no vessel irregularities, vasospasm, or dissection noted along the course of the MMA Vecta46 placement. No immediate procedural complications were noted and all cases achieved complete distal MMA occlusion. Figure 1: (A) Ophthalmic (black) and petrous (white) collaterals off the anterior and posterior MMA branches, respectively. (B) Contralateral (green) and falx (orange) penetration of the MMA branches. (C) Proximal coiling of the anterior and posterior MMA branches (black). Conclusion The Vecta46 intermediate catheter is a powerful tool for MMA embolization that allows the safe and effective placement of an intermediate catheter in the proximal MMA trunk. This allows for simple catheter exchange for multiple liquid embolic pedicle embolizations and significant support for navigating microcatheters to distal MMA branches.

A67Advanced cardiothoracic Simulation -how to do it and who is it for?

There is a large backlog in surgery due to covid as well as surgical training [1]. We explored the feasibility of a dry lab simulation environment to teach advanced surgical specialty skills to learners with different levels of experience. Session description: We ran 5 cardiothoracic surgical simulation courses over 2021-2022 with a total of 61 delegates. We covered coronary anastomosis, aortic valve replacement, video-assisted-thoracoscopic-surgery (VATS) lung wedge resection and pulmonary vessel dissection. Each skill station ran for 40 minutes including a 15-minute description and real-time demo. Target audience: Participants included 36 medical students, 14 specialty doctors and 11 foundation doctors. We used synthetic plastinated and resin printed models with modular metal frames to help with retraction and suspension of the area of interest for the cardiac models. For the VATS models a laptop with connected angled endoscopic camera was utilized. The lung models were 3D printed. 88% of all participants were able to complete all procedures successfully under supervision. 96% of all participants increased in confidence with the procedure following simulation compared to before. Interestingly only 44% of specialty trainees described themselves as confident in some procedures prior to simulation. Of the medical student cohort 95% had not had any previous simulation or surgical experience prior. We have demonstrated the feasibility of a dry lab simulation programme for candidates of all experiences in cardiothoracic surgery. Confidence in surgical technique is low during the COVID era. Simulation improved confidence in surgical technique and must be offered more widely to enhance training experiences. No experience is necessary for successful simulation. Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

Prevalence of aortic aneurysms and dissections in patients with systemic vessel aneurysms and dissections; matched case-control study using a national sample cohort.

Aneurysms in systemic arteries are rare, and little is known about their relationship with aortic aneurysms. In this study, we aimed to evaluate the prevalence of aortic aneurysms and dissections (AAD) in patients with other systemic vessel aneurysms and dissections (OVAD) and identify their potential risk factors. This cross-sectional study used a nationwide representative cohort sample from the Korea National Health Insurance Service-National Sample Cohort database. We defined OVAD as systemic vessel aneurysms and dissections excluding intracranial and aortic dissections and aneurysms. With a total of 690 OVAD patients and 2,760 non-OVAD matched controls, we investigated the prevalence of AAD in patients with OVAD and potential risk factors for their concurrence using the χ2 test and logistic regression. The prevalence of AAD in patients with OVAD was 10.6% (73/690) and 0.3% (9/2,760) in patients with non-OVAD. The adjusted odds ratio (OR) for having concurrent AAD with OVAD was 37.56 (95% CI: 18.29-77.12, p < 0.001) after stratification by sex, age, income, region of residence and after adjustment for hypertension, diabetes mellitus, dyslipidemia, and extent of disability. The adjusted ORs of AAD were significantly higher in females [adjusted OR = 47.63 (95% CI: 10.72-211.55)], and individuals aged ≥60 years [adjusted OR = 28.18 (95% CI: 13.42-59.17)], as well as those without hypertension [adjusted OR = 95.44 (95% CI: 18.21-500.23)], diabetes mellitus [adjusted OR = 46.39 (95% CI: 18.85-114.17)], without dyslipidemia [adjusted OR = 60.99 (95% CI: 20.83-178.56), p < 0.001 for all]. The prevalence of AAD significantly differed by according to specific sites of OVAD in carotid artery, upper extremity artery, iliac artery, lower extremity artery, and splanchnic artery (p < 0.001 for all). The prevalence of AAD in patients with OVAD was 37.56 times higher than that in the matched population. We may approach aneurysms as systemic diseases and further investigations of pathophysiology would help to clarify the relationships between AAD and OVAD.

Recipient Vessel Dissection Technique in Diabetic Foot Patients with Perivascular Fibrosis.

Diabetic foot ulcers are becoming more prevalent, and microsurgical free flaps are gaining popularity in salvaging the foot after postdebridement. The perivascular fibrosis around the recipient vessels often makes the dissection of vessels difficult. In this article, we describe a technique of dissection in such situations where fibrosis and dissection of vessels are fraught with danger. In the period from November 2020 to May 2023, 72 free flap reconstructions of the diabetic foot were done at our institute using this technique, with a success rate of 95.8%.

Single-Center Experience With Inner-Branched Endograft for the Treatment of Pararenal Abdominal Aortic Aneurysms.

To report a single-center result of patients with pararenal aneurysms treated with inner-branched endograft. This retrospective study analyzed prospectively collected data of patients treated with elective inner-branched endovascular aneurysm repair (iBEVAR) using an Artivion® E-xtra custom-made endograft. Primary endpoints were clinical and technical success after iBEVAR. Secondary endpoints were overall survival, target vessel patency during follow-up, aneurysm-related mortality, and freedom from reintervention. Over a 56-month period, a total of 23 patients (19 men; 72.3±7.2 years) were treated with iBEVAR with a mean follow-up of 15 months. Technical success was achieved in 96% of procedures, incorporating 87 inner branches. Two (8.3%) intraoperative complications (target vessel dissection) were reported, without additional reinterventions needed. Two (8.3%) patients died within 30 days after initial procedure. One due to respiratory failure and the other from an ischemic stroke. During follow-up, 3 patients (13%) required reintervention, either to repair a type I or type III endoleak (n=2) or to place an iliac-branched device, that did not succeed during the initial iBEVAR procedure (n=1). Primary target vessel patency and freedom from reintervention during follow-up was, respectively, 98.9% and 87%. We revealed no aneurysm-related mortality. Overall survival was 78.3%. The present study confirms previous findings that iBEVAR on the Artivion® E-xtra design platform is an effective and safe procedure achieving high technical success rate in the treatment of pararenal abdominal aortic aneurysms. Inner branched stent-graft configuration combines the benefits of FEVAR and outer-branched stent-graft technology. Implementation of inner branches in stent-grafts is gradually becoming more widespread for the treatment of aneurysms. This report supports the safe and high technical success rate of inner branched stent-grafts in treatment of pararenal abdominal aortic aneurysms.