Distal Anastomosis Research Articles

SURGICAL TREATMENT OF EARLY POSTOPERATIVE COMPLICATIONS OF ENDOVASCULAR REVASCULARIZATION OF A MULTI-LEVEL STENOTIC-OCCLUSIVE ATHEROSCLEROTIC LESION OF THE FEMORAL-DISTAL ARTERIAL BED

The use of endovascular techniques remains the only chance to restore blood flow under the conditions of a distal stenotic-occlusive process. Nevertheless, under the conditions of endovascular reconstructive surgery of the distal arterial bed, unsatisfactory results occur in 6-32% of cases in the form of thrombosis or restenosis of the reconstruction segment due to the progression of signs of limb ischemia.
 The aim is to improve the results of endovascular revascularization of multilevel atherosclerotic stenotic-occlusive femoral-distal arterial bed by surgical treatment of postoperative complicated forms of revascularized infrainguinal arterial bed.
 Materials and methods. 164 patients with multilevel stenotic-occlusive lesions of the femoral-distal arterial bed were under observation. Ultrasound dopplerography was used to select the volume of reconstructive intervention. Endovascular angioplasty of the femoral-popliteal segment (I stage) was performed with Pan Medical (PEKICO), OPTA PRO (Cordis) balloon catheters. In 41.10% of observations, balloon angioplasty of the femoral segment was continued with the placement of a stent - a self-expanding Smart ControL stent (Cordis), a self-expanding Carbostent stent (Flype), a self-expanding stent - Vascular stent (BARD) was used. Endovascular angioplasty of the arteries of the tibial segment (II stage) was performed using long balloons (80-150 mm) Armada 35 LL manufactured by Abbott Vascular (USA) and Amphirion Deep (Medtronic) Coyote (Boston Scientific). 76 intraluminal and 33 subintimal angioplasty were performed. When performing subintimal angioplasty, CompleteSE (Medtronic), Smart (Cordis) and CompleteSE (Medtronic) stents were used. In 40 patients, angioplasty was performed on two arteries of the leg, in 33 - on one of the tibial arteries. At the first stage, an open reconstruction of the femoral-popliteal segment was performed - the formation of a femoral-popliteal autovenous shunt. In 20 (21.98%) observations, the proximal anastomosis was formed at the level of the bifurcation of the thoracic cavity during simultaneous deep fundoplasty. In 36 (39.51%) observations, the distal anastomosis of the autovenous shunt was formed at the level of the PCA by the end-to-end type. A 6F Check-Flo Performer (USA), Balton (EU) introducer was used to ensure the change of the balloon catheter. Long balloons (80-150 mm) Armada 35 LL manufactured by Abbott Vascular (USA) and Amphirion Deep (Medtronic) Coyote (Boston Scientific) were used, CompleteSE stents (Medtronic) – 23 cases, Smart (Cordis) – 24 observations.
 Conclusions. The early postoperative period of endovascular revascularization of a multilevel stenotic-occlusive lesion of the femoral-distal arterial bed is complicated by thrombosis of the popliteal-tibial segment in 15.9% of observations. Thrombosis of the popliteal segment is detected 2.7 times more often after endovascular angioplasty of one of the tibial arteries during endovascular revascularization of a multilevel stenotic-occlusive lesion of the femoral-distal arterial bed than during endovascular angioplasty of two tibial arteries. The effectiveness of the use of rheological thrombus extraction by the Angiojet system in the surgical treatment of postoperative thrombosis of the popliteal segment, which is formed in 15.9% of observations after endovascular revascularization of a stenotic-occlusive lesion of the femoral-distal arterial bed, is equal to 84.6%.

Optical coherence tomography as a method for assessing the conduit-anastomosis-artery system in patients after coronary artery bypass grafting

Background. Coronary artery bypass grafting (CABG) remains the most common cardiac surgery in the world. In the long-term follow-up period after surgery, graft failure occurs in a substantial proportion of CABG conduits and is a complex pathomorphological process. Optical coherence tomography (OCT) is a high-resolution intravascular imaging modality that allows to assess in-vivo endothelial integrity.Aim. To substantiate the efficacy and safety of OCT assessment of the conduitanastomosis-artery system in CABG patients.Methods. The prospective observational cohort study included 21 patients with chronic coronary artery disease who underwent CABG. 3–5 days after CABG, patients underwent OCT and angiography of arterial and vein grafts, including distal anastomosis and nearby segment of the target coronary artery. At 12-month follow-up, all patients underwent repeated OCT and angiography of the conduitanastomosis-artery system to assess the changes. The primary endpoint of the study was graft failure; secondary endpoints of the study included unplanned repeat myocardial revascularization, cardiac death, and myocardial infarction due to graft failure.Results. At 12-month follow-up, 14.3% of graft failure and 9.5% of cases of unplanned repeated myocardial revascularization were registered. In most cases of graft failure, primary OCT revealed pronounced changes in the conduit and the native coronary artery (conduit/artery diameter ratio was more than 2 mm), whereas the diameter of the coronary artery anastomosis was less than 2.5 mm. Myocardial infarctions and death within 12 months were not registered.Conclusion. Thus, OCT is an effective and safe intravascular imaging technique for assessing coronary arteries and the conduit-anastomosis-artery system. OCT makes it possible to identify morphological changes in coronary bypass grafts, which can predict their early failure. The conduit/artery diameter ratio greater than 2 and target coronary artery diameter less than 2.5 mm was associated with graft failure within 12 months after CABG.

Postoperative Morbidity Following Loop Ileostomy Reversal after Primary Elective or Urgent Surgery: A Retrospective Study with 145 Patients.

Temporary loop ileostomy is usually performed to protect distal anastomosis or to treat urgent surgical cases. The aim of this study is to evaluate whether, after primary urgent stoma construction, patients undergoing ileostomy reversal have different postoperative outcomes compared with patients who have protective stoma performed in an elective setting. A retrospective observational study was conducted including patients who underwent ileostomy reversal. Baseline patient characteristics and perioperative outcomes were collected in a single database. The overall morbidity rate during recovery was fixed as a primary outcome. Between 2011 and 2021, the complete data records of 145 patients were evaluated. After ileostomy reversal, the postoperative morbidity rate did not differ between groups (14.4% vs. 11.5%, p = 0.790). Even considering each complication, such as ileus, small bowel obstruction, bleeding and wound infection, no significant difference was detected. Similarly, the time to first flatus was 2.25 ± 1.24 vs. 2.1 ± 0.99 (p = 0.379) and the length of hospital stay was 5.43 ± 3.03 vs. 5.84 ± 5.15 (p = 0.568). The only significant factor associated with postoperative complications on logistic regression analysis was the presence of comorbidities (OR 4.49; 95% CI 1.19-29.4, p = 0.05). In the present cohort of patients, there was no difference in the postoperative complication rate after stoma closure following elective or urgent indication for surgery.

Outcomes of Early Oral Feeding Compared to Delayed Feeding in Children after Elective Distal Bowel Anastomosis.

Conventionally, oral feeds after distal bowel anastomosis surgery (ileostomy/colostomy closure) are delayed until after bowel peristalsis is established. The safety of an early feeding regimen is not established in children. This study compared early feeding regimens with delayed feeding in children undergoing elective intestinal anastomosis surgeries. In this retrospective multicentric cohort study, children undergoing elective distal bowel anastomosis surgery were divided into Group A (oral feeds allowed within 6 h) and Group B (delayed feeds). The two groups were compared for the incidence of abdomen distension, vomiting, surgical site infection, duration of analgesia, length of hospital stay, and readmission rate. During the study, 58 patients were included: Group A (n = 26) and Group B (n = 32). The duration of analgesia (1.9 vs. 4.01 days) and length of hospital stay (3.38 vs. 5.0 days) were significantly less in Group A. Abdominal distension (7.7% vs. 15.6%), vomiting (11.5% vs. 15.6%), surgical site infection rate (3.8% vs. 12.5%), and readmissions (0% vs. 3.1%) were less in Group A, but statistically not significant. Early feeding after the elective restoration of distal bowel continuity can be safely practiced in the pediatric population. It is associated with a reduced need for analgesia and shorter hospital stay.

Coronary Artery Bypass with Myxedema

Introduction Hypothyroidism increases the risk of cardiovascular complications in patients scheduled for coronary artery bypass grafting. Atrial fibrillation is one of its cardiac complications. Case Report Our 45-year-old male patient was admitted to the Emergency Medicine Clinic of our hospital with chest pain that started in the left arm and extended to the chin 2 days ago. It was noted that the patient had hypothyroidism, but did not have any medication for the disease. On physical examination, dry and pale skin, sparse coarse hair, non-pitting edema were diagnosed with acute coronary artery disease. No signs of ischemia were observed on the ECG at the time of admission, but bradycardic sinus rhythm was recorded. The patient was started to be followed up with the diagnosis of NON-ST myocardial infarction. Nitroglycerin 0.25 - 2 mcgr/h and morphine 2 mg were administered intravenously to the patient whose anginal complaints continued after admission. Anginal complaint continued was operated in 1:1 mode by attaching an intraaortic balloon pump (Maquet Sensation 7Fr 40 cc, Datascope CS300 console) via the left femoral artery. Surgery procedure: The patient was performed with median sternotomi (aortic, two-stage cannulation). While the patient was cooled to 32 degrees and given blood cardioplegia (St. Thomas II) and applied topical cold. After distal anastomoses were performed with saphenous vein graft. Total cross-clamp time was 60 min. Epinephrine was given for bradycardia sinus rhythm. No cardiovascular complications were encountered while being followed in the intensive care unit. The patient was discharged on the 6th postoperative day. Conlucion: Our case, who was taken to emergency CABG operation with myxedema, was discharged without any cardiovascular, respiratory or metabolic complications both in the perioperative and postoperative periods. In this case, the major stress caused by cardiovascular surgery was successfully overcome by both the cardiovascular surgery team and the anesthesiology team.

Head-to-head: Zone 2 vs. Zone 3 frozen elephant trunk

Total arch replacement via frozen elephant trunk (FET) is a strategy for managing complex thoracic aortic pathologies involving the arch and descending thoracic aorta (DTA). The FET procedure involves the distal anastomosis of the FET hybrid prosthesis at a chosen aortic arch zone. Though distal anastomosis has been traditionally performed at Zone 3 (Z-3-FET) of the aortic arch, recent practice has seen a significant increase in Zone 2 FET (Z-2-FET). The literature concerning independent Zone 2 and 3 studies and head-to-head comparative studies suggest that Z-2-FET is the superior approach, yielding more favourable results overall, except for aortic remodelling. The improved clinical outcomes achieved with Z-2-FET can be attributed to the shorter operative times, including cardiopulmonary bypass duration, due to the ease and increased surgical site exposure at the aortic arch using this technique. The slightly inferior aortic remodelling observed in Z-2-FET can be explained by the decreased coverage of the DTA distally by the FET stent graft. However, this difference in results can also be attributed to the complexity and severity of the underlying pathology and the surgical approach adopted. The prospect of utilising Zone 0 FET (Z-0-FET) is highly promising, with some studies hinting at its superiority over Z-2-FET. Nevertheless, studies are needed to determine the efficacy of Z-0-FET and directly compare it to Z-2-FET to reach a definitive consensus on the most optimal FET technique. The present literature review aims to provide an overview of major intraoperative and postoperative outcomes achieved with Z-2-FET and Z-3-FET and summarise evidence from studies directly comparing them. Another aim of this narrative review is to explore current literature trends on Z-0-FET uptake.

Decrease of Graft Failure Rate by Improving Tactics and Surgical Techniques in Extraanatomic Bypass Operations

We analized the early and late postoperative complications that occurred after 693 bypass operations (574 anatomic and 119 extra-anatomic) performed in 10 consecutive years (1997-2006). The bypass graft failures (infection + thrombosis) treatment and the subsequent evolution of the patients were detected by analyzing patients’ readmissions made to solve these major post-bypass complications. The follow-up period extended up to 12 years after the primary arterial bypass reconstruction. In this period we registered: 89 secondary arterial reconstructions for early and late graft thrombosis; 8 healings after removal of the infected prostheses, followed by extraanatomic bypass operations (7 obturator bypass + 1 axillo-bifemoral bypass). The most frequent vascular prosthesis infection sites were the Scarpa triangle and the thoraco-abdominal subcutaneous segment of the axillo(bi)-femoral graft. Major amputations after extraanatomic bypass operations: at 4 years postoperatively for axillo(bi)-femoral operations the amputation rate was 17.6%, while for crossover operations it was 7.5%. Perioperatory mortality after anatomic bypass operations = 2 intraoperatory and 8 postoperatory (1.38%/574 operations); perioperatory mortality after extraanatomic bypass operations: 2 postoperatory deaths (1.68%/119 operations), 1 after axillo-femoral prosthesis infection and 1 after acute myocardial infarction. In order to reduce the graft major complication rate after extraanatomic bypass operations we took the following measures: 1. When there are arterial occlusive lesions distal to the femoral tripod we ensured an adequate outflow which favores the long-term patency of the extraanatomic graft; this goal was obtained by 2 methods: by enlargement profundoplasty and/or by performing an additional distal bypass towards the popliteal artery or towards the subgenicular arteries. The distal subgenicular anastomosis was made between a venous graft and the distal outflow artery for reducing the intimal hyperplasia. 2. For crossover bypass operations we often used autologous vein grafts; 3. In crossover ilio-femoral bypass operation with venous graft we avoid the graft compression in its path through abdominal wall by passing the graft through a stable caliber hole made in a polypropylene closure mesh of the abdominal wall. 4. We promote the tunneling of the axillo-femoral prosthesis through the subaponeurotic muscular tissue because this tissue better protects the prosthetic graft against infection. 5. In order to reduce the groin prosthesis infections, we prefer performing ilio-femoral crossover bypass instead of femoro-femoral one. 6. The obturator bypass remains a valuable tratment for groin infected prosthesis.

Femorodistal bypasses using venous “cuffs”

Background/Aim. Although distal venous patch and cuff techniques are recommended to improve the patency of by-pass in the lower extremities, the advantage of these techniques remains unproven. Autovenous bypass graft remains the method of choice, but when there is no possibility of using the great saphenous vein, the venous cuff method may have an advantage. The aim of this study was to evaluate the results of femorodistal bypass procedures with a venous cuff in critical lower extremity ischemia. Methods. The study described the results of femorodistal bypass procedures after a follow-up period of 6 to 24 months. We followed 28 patients with distal composite anastomosis of femorodistal arterial reconstruction. Indications for surgical treatment were set on the basis of the clinical exam and morphological criteria based on multidetector computed tomographic angiography. Three types of distal graft-arterial anastomoses were applied: Miller?s cuff, Taylor?s patch, and St. Mary?s vein boot anastomosis. Results. After 6 months of surgery, all bypasses were passable; after one year, 2 (7%) patients had graft occlusion and above-knee amputation, and 8 (28%) patients died; after 24 months, 18 (64%) patients had primary bypass patency. Conclusion. Femorodistal bypass procedures using a synthetic graft and venous cuff have good long-term results. The optimal anastomosis type is St. Mary?s boot. A longer follow-up period and comparison with the autovenous bypass are necessary for a more detailed assessment of the final conclusion.

High amylase concentration in drainage liquid can early predict proximal and distal intestinal anastomotic leakages: A prospective observational study.

Anastomotic leak (AL) is a serious complication in digestive surgery. Early diagnosis might allow clinicians to anticipate appropriate management. The aim of this study was to assess the predictive value of amylase concentration in drain fluid for the early diagnosis of digestive tract AL. Hundred and fourteen consecutive patients "at risk" of AL, in whom a flexible drainage was placed by surgeon's choice after digestive anastomosis were included. Patients with eso-gastric, bilio-digestive, and pancreatic anastomoses were excluded. Drain amylase measurement (DAM) was routinely performed on postoperative day (POD) 1, 3, 5-7. DAM values were compared between patients with postoperative AL versus patients without AL. A receiver-operating curve (ROC) with calculation of the areas under the ROC curves area under curves was performed and a cutoff value of DAM was calculated. AL occurred in 25 patients (AL group) and 89 patients did not present AL (C group). The mean DAM was significantly higher in AL group versus C Group on POD 1, 3, and 5. A cutoff value of 307 IU/L predicted the occurrence of AL with a sensitivity and specificity of 91% and 100%, respectively. Positive and negative predictive values were 100% and 97.5%, respectively. Patients with AL had an elevated DAM prior to the appearance of any clinical signs of AL. High level DAM could accurately predict AL for proximal and distal digestive tract anastomoses. This simple, noninvasive, and low-cost method can accurately predict early AL and help physicians to perform appropriate imaging and treatment.

Direct innominate artery ostial cannulation using retrograde cardioplegia cannula in Type A dissection

Objective: Axillary and innominate artery (IA) cannulation using side graft has some limitations in patients having ascending aortic dissection (AAD) with flap extending in major neck vessels. We retrospectively analyzed the outcomes of a direct under vision innominate ostial cannulation strategy for antegrade cerebral perfusion (ACP) using a retrograde balloon-tip cardioplegia cannula. Patients and Methods: This was a retrospective analysis of all patients who were operated on for AAD with a dissection flap extending into major neck vessels between November 01, 2020 and November 30, 2022. Demographic data were noted, and comorbidities were listed. The kind of surgery patients underwent was noted: three patients underwent modified Bentall's procedure, five had to ascend aortic replacement, and one patient underwent David's procedure. All patients had open distal anastomosis using moderate hypothermia with ACP by direct under vision cannulation of the true lumen of the IA using a balloon-tip retrograde cardioplegia cannula. Intraoperative parameters such as cross-clamp time, cardiopulmonary bypass time, temperature range during circulatory arrest, and total operative time were noted. The primary outcome was a comparison of the incidence of stroke, seizures, and psychosis and the secondary outcome was an analysis of end-organ malperfusion, intensive care unit (ICU) stays, total hospital stay, and 30-day mortality. Results: We retrospectively analyzed the surgical data of nine patients who were operated on between November 01, 2020 and November 20, 2022 by this technique and found that the incidence of stroke, seizures organ malperfusion, ICU stay, and hospital stay was comparable to other techniques of ACP (axillary artery/direct IA cannulation), but the operative time was a less, and local complications due to axillary cannulation such as shoulder pain and upper limb weakness and seroma were not seen. Conclusion: Direct vision cannulation of the true lumen of the IA using a retrograde balloon-tip cannula is a cost-effective and time-saving method. It evades the limitations of well-established ACP techniques such as direct IA cannulation using Seldinger's technique which is a blind procedure and also has no local complications of the cannulating right axillary artery. Our results show that this procedure is less time-consuming and is noninferior to the other two methods of ACP in patients getting operated on for AAD with open distal anastomosis under moderate hypothermia. Further studies with a larger sample size are needed to validate this preliminary study.

СЛУЧАЙ ЭТАПНОГО ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ ТРОМБОЗА ПОРТАЛЬНОЙ И НИЖНЕЙ ПОЛОЙ ВЕНЫ С СЕГМЕНТАРНЫМИ НЕКРОЗАМИ ТОНКОЙ КИШКИ

Acute venous mesenteric thrombosis can be combined with thrombosis of the inferior vena cava, portal vein, or be their result. In this situation, small bowel ischemia manifests itself as segmental necrosis, with the appearance of new foci of necrosis in time. Diagnostics of the prevalence of venous thrombosis and attack control surgery in the background of anticoagulant therapy, described in clinical observation, allowed the determination of the level of damage to the inferior vena cava, control the formation of new necrosis of the intestinal wall, improve blood supply to the remaining parts of the intestine after double resection, and perform delayed distal anastomosis of the proximal small intestine with ileostomy under conditions of confirmed adequate viability of preserved sections of small intestine.

Bilateral Iliac Endobypass Solution in Iliac Artery Rupture during TEVAR Procedure: A Case Report and Review of the Literature

Iliac artery rupture is a demanding complication that can occur during endovascular procedures, particularly when large-caliber introducers are required. We present the first case in the literature on the endobypass technique, a quick and effective reconstruction method for the iliofemoral axis. This clinical case highlights that thoracic endovascular aortic repair procedures require large-caliber introducers into the femoral and iliac arteries to allow passage of the delivery system. These arteries may be diseased, representing a high risk of rupture. In our case, placing a 20 Fr introducer, the iliac artery ruptured bilaterally. Therefore, we performed an endobypass deploying Viabahn stent-grafts into the common iliac artery and manually performed distal anastomosis on the femoral bifurcation.

Easy to say, hard to do. To the anniversary of two fundamental discoveries. Part 2

On the eve of the anniversaries of two historical events: the 145 th anniversary of the experiments in which Eck's fistula was performed and the 55th anniversary of the successful clinical approbation of the selective distal splenorenal anastomosis, a retrospective analysis of the key historical stages in the development of portal hypertension surgery was performed: from the first attempts to describe the anatomy of the hepatic vascular system, explaining its purpose in the body, the development of direct portacaval anastomosis, and the widespread use of selective splenorenal anastomoses, to the Transjugular Intrahepatic Portosystemic Shunt procedure and orthotopic liver transplantation. Meantime, the emphasis has been focused on the most colorful characters of researchers and clinicians who passed this path. The expediency of an integrated approach in solving the problems of portal hypertension with the development of both fundamental and applied clinical and organizational aspects has been substantiated. It is shown that the discoveries born from summarizing the results achieved by numerous researchers have contributed to a better understanding of this field of medicine, have become a solid foundation for what we have today and are a reliable platform for a successful start into the future.

Minimal Extracorporeal Circulation and Microplegia in the Setting of Urgent Coronary Artery Bypass Grafting.

We aimed to analyse the performance of minimal invasive extracorporeal circulation (MiECC) concomitantly with Microplegia, in patients with recent myocardial infarction (MI) undergoing urgent coronary artery bypass grafting (CABG) surgery. We included patients with a recent MI (≤7 days) undergoing isolated CABG surgery using MiECC. The primary endpoint was a major cardiovascular or cerebrovascular event (MACCE). In a secondary analysis, we compared our institutional Microplegia concept with the use of a crystalloid single-shot cardioplegic solution. In total, 139 patients (mean ± standard deviation (SD) age 66 ± 10 years) underwent urgent CABG surgery using Microplegia; 55% (n = 77) of the patients had an acute MI within 1-7 days preoperatively; 20% (n = 28) had an acute MI within 6-24 h; and 24% (n = 34) had an acute MI within <6 h preoperatively. The number of distal anastomoses was a geometric mean of 4 (95% confidence interval 3-4). The MACCE and in-hospital mortality were 7% (n = 10) and 1% (n = 2), respectively. The results were confirmed in a secondary analysis comparing Microplegia with crystalloid cardioplegic solution (n = 271). The use of MiECC with Microplegia in urgent CABG surgery is feasible and safe and provides a straight-forward intraoperative setting. Therefore, it can also be considered to retain the benefits of MiECC in urgent CABG surgery.

Anomalous Aortic Origin of the Right Coronary Artery: A Case Report and Review of the Literature.

Various surgical methods are available for the management of anomalous aortic origin of the right coronary artery (AAORCA), preferably unroofing when the intramural segment can be identified.Hypoplasia of the proximal segment, an acute take-off angle, and close proximity to the intercoronary pillar or commissure are limitations to unroofing, and alternative approaches are more appropriate.Coronary artery bypass graft, with either arterial or venous graft, can be performed when unroofing and reimplantation are not feasible. Measuring the distal anastomosis flow may help with a decision regarding native coronary artery ligation. It remains undetermined whether arterial or venous grafts provide superior outcomes.

Clampless 2 Device: Experimental Study of a Lateral Aorto-Prosthetic Anastomosic Device Without Clamping or Suturing

To offer an alternative to conventional techniques of lateral prosthetic anastomosis on arteries which require a long training, and impose an extensive open surgery, we are proposing the clampless 2 device (C2D) implanted by a simple arterial puncture and allows a lateral implantation of a polytetrafluoroethylene (PTFE) vascular graft in an artery, without arterial clamping or suture. C2D is a "T" shaped 25-mm long and 8-mm diameter Nitinol stent with a 6-mm PTFE graft prosthesis mounted laterally on the stent, and implanted in an artery, via a 21-French sheath, and a compliant balloon inflation. Invitro testing of the C2D was first performed on a bench including a segment of a 7-mm internal diameter pig abdominal aorta. A series of 5 consecutive C2D implantation was analyzed with evaluation of the implantation time and the fluid losses at a fluid pressure of 80 and 150mm Hg. The C2D implantation was finally controlled by angioscopy. An aorto-iliac bypass was then secondly performed on 8 living sows, with a side-to-end C2D implantation in the infrarenal abdominal aorta, followed by a conventional end-to-end prosthetic left iliac trunk anastomosis. The C2D and distal conventional anastomotic times were evaluated, as well as the total operative time and blood loss. A postoperative angiogram was systematically performed. The C2D was successfully implanted in all 5 invitro tests, with an average implantation time of 2'58 (range: 2'25-3'22). The mean value of fluid losses was 84ml (range: 67-94ml), with no fluid leakage occurring at 80- and 150-mm Hg pressure. All anastomoses were patent after macroscopic study by angioscopy with a perfect application of the stent in the aortic wall. In 8 living sows (mean weight: 42kg, 37-50kg), an aorto-left iliac bypass was successfully implanted in all cases, with a total mean procedure time of 101min (range: 90-130min), and an average fluid loss of 77ml (range:20-120ml). The mean implantation time was 4'39 (range 3'29-5'52) for C2D and 16min (range 12-17min) to perform the conventional distal prosthetic-iliac anastomosis. Systematic arteriographic and angioscopy control showed perfect patency of the C2D implantations. Preliminary invitro and acute invivo testing of C2D implantation show good early results, allowing further long-lasting pig experiments on the way to human homologation.

Secondary endovascular procedures improve overall patency and limb salvage in patients undergoing in situ saphenous vein infragenicular bypass.

Secondary interventions strongly improves patency and limb salvage rates in patients undergoing infrainguinal vein bypass. The aim of this study was to evaluate the influence of secondary endovascular procedures performed during the follow-up on patency and limb salvage in patients with critical limb-threatening ischemia (CLTI) undergoing in situ saphenous vein infragenicular bypass. From January 2018 to December 2019 541 patients in 43 centers have been enrolled into the LIMBSAVE registry (treatment of critical Limb IschaeMia with infragenicular Bypass adopting in situ SAphenous VEin technique). In all patients a strict surveillance program with Duplex scan was established (1, 3, 6, 9, 12, 18, 24 months). During the follow-up indications for endovascular procedures were anastomotic stenoses, improvement of run-in (iliac stenosis) or run-off (tibial vessels' stenoses or occlusions). Two-year estimated outcomes in terms of overall patency, and limb salvage were analyzed by life-table analysis (Kaplan-Meier test). Outcomes obtained in patients undergoing endovascular procedure (Group-endo) were compared by means of Gehan-Breslow-Wilcoxon Test with those obtained in patients with no secondary endovascular procedure during the follow-up (Group-no endo). Two groups were homogeneous in terms of demographics and intraprocedural details. Overall mean duration of follow-up was 12.1 months (range 1-24). During the follow-up period (>30 days) 55 endovascular procedures were performed in 49 patients (9.1%) (Group-endo). Most of endovascular procedures (37/55, 67.3%) was performed to treat stenoses at proximal or distal anastomosis. Secondary endovascular procedures (40/55, 72.7%) were predominantly performed within 6 months from the index procedure. Estimated 2-year overall patency (97.9% vs. 85.2%, P=0.05), and limb salvage (100% vs. 93.9%, P=0.05) rates were significantly better in Group-endo. Secondary endovascular procedures in patients with CLTI undergoing in situ saphenous infragenicular bypass significantly improve the rates of overall patency and limb salvage in the mid-term period.

Hypertrophic Obstructive Cardiomyopathy Repair with Coronary Artery Bypass Surgery: A Case Report

Background: Hypertrophic obstructive cardiomyopathy (HOCM) is a cardiac condition of an abnormal interventricular septum (IVS) thickening. It is due to an autosomal dominant mutation in sarcomeric protein genes. It had many phenotypes with different distribution of myocardial hypertrophy. Septal myectomy remains the treatment of choice for hypertrophic obstructive cardiomyopathy resistant to medical therapy. However, controversy exist regarding standard treatment option(s). Description of the Case: Here we described a case of 47-year-old patient admitted with diagnosis of acute coronary syndrome, with typical chest pain of angina class II, shortness of breath class-II (NYHA), smoker on regular renal hemodialysis. Echocardiography showed HOCM, IVS thickening, normal Left ventricle global systolic function and mild to moderate eccentric regurge. Coronary angiography revealed normal left main with total (LAD) proximal occlusion, proximal and mid (LCX) (50%) occlusion, first (OM) mid (90%) lesion, (RCA) dominant with non-flow limiting lesions. He was submitted to open heart surgery with four grafts, sub-valvular myomectomy, and successful myomectomy. Distal anastomosis was done first then myomectomy then proximal anastomosis. Patient extubated after (9) hours with stable hemodynamics and complete neurological condition, with accepted drains output. He gradually weaned from inotropic support and chest drains removed on 3rd postoperative day. All lines and pacemakers were removed, the wound was dry with stable sternum and improvement of all symptoms. Then discharged home after 9 days of hospital stay on medical treatment. Postoperative echocardiography showed significant improvement. Conclusion: Surgical treatment is the standard option in treatment of HOCM to improve symptoms.

A Partial Clamp During Off-Pump Coronary Artery Bypass Grafting Can be Safely Used When Utilizing the Calcium Score with Computed Tomography For Evaluating The Ascending Aorta.

No previous study has shown that the volume of calcium score is useful for evaluating the aorta when performing a partial clamp (PC). The purpose of this study was to examine the effect of different clamping strategies during off-pump coronary artery bypass grafting (OPCAB), in terms of the incidence of postoperative stroke using the calcium score of the ascending aorta. We retrospectively reviewed 339 patients, who underwent isolated OPCAB between August 2013 and March 2021. There were two groups of patients, depending on the procedure. A PC was used for proximal anastomoses in 130 (38.3%) patients. A clampless proximal facilitating anastomotic device (CFD) was used in 107 (31.5%) patients. We prescribed preoperative CT for all patients, and the Agatston score was used. The calcium score significantly was higher in the CFD group than in the PC group (29.7 ± 66.5 vs. 1819.8 ± 2391.5, < 0.001). The number of distal anastomoses and operative time were not significantly different between the two groups. There was no mortality and three strokes occurred at the 30-day follow up. Two strokes occurred in the PC group (1.5%) and one in the CFD group (0.9%), which was not significantly different (P = 0.98). A PC does not increase postoperative stroke incidence compared with a CFD, when utilizing calcium score evaluation in OPCAB.

Total arterial revascularization coronary artery bypass surgery in patients with atrial fibrillation.

Atrial fibrillation (AF) is a relatively common comorbidity among patients referred for coronary artery bypass grafting (CABG) and is associated with poorer prognosis. However, little is known about how surgical technique influences survival in this population. The current analysis aimed to determine whether total arterial revascularization (TAR) is associated with improved long-term outcomes in patients with preoperative AF. We analyzed patients' data from the HEIST (HEart surgery In atrial fibrillation and Supraventricular Tachycardia) registry. The registry, to date, involves five tertiary high-volume centers in Poland. Between 2006 and 2019, 4746 patients presented with preoperative AF and multivessel coronary artery disease and underwent CABG. We identified cases of TAR and used propensity score matching to determine non-TAR controls. Median follow-up was 4.1 years (interquartile range [IQR], 1.9-6.8 years). Propensity matching resulted in 295 pairs of TAR vs. non-TAR. The mean (standard deviation [SD]) number of distal anastomoses was 2.5 (0.6) vs. 2.5 (0.6) (P = 0.94) respectively. Operative and 30-day mortality was not different between TAR and non-TAR patients (hazard ratio [HR] and 95% confidence intervals [CIs], 0.17 (0.02-1.38); P = 0.12 and 0.74 [0.40-1.35]; P = 0.33, respectively). By contrast, TAR was associated with nearly 30% improved late survival: HR, 0.72 (0.55-0.93); P = 0.01. This benefit was sustained in subgroup analyses, yet most pronounced in low-risk patients ( < 70 years old; EuroSCORE II < 2; no diabetes) and when off-pump CABG was performed. TAR in patients with preoperative AF is safe and associated with improved survival, with particular survival benefits in younger low-risk patients undergoing off-pump CABG.