Donor Vessels Research Articles

A Case of Successful Simultaneous Pancreas-Kidney Transplantation Using the Injured Pancreas Graft

ObjectiveGraft injuries sometimes occur and may cause complications such as the leakage of pancreatic secretions, which is often lethal. We report our experience of a case of successful simultaneous pancreas-kidney transplantation using injured pancreas graft. Patients and methodsThe recipient was a 57-year-old woman with type 1 diabetes mellitus, and the donor was a 30-year-old man with a brain injury. In the donation, the pancreas parenchyma, splenic artery, and gastroduodenal artery were injured iatrogenically. We therefore reconstructed these arteries using vessel grafts and then performed simultaneous pancreas-kidney transplantation. ResultsFive days after transplantation, we noted a high titer of amylase in the ascites; therefore, we performed an urgent laparotomy. The origin of the amylase was the injured pancreatic parenchyma, and continued washing and drainage were carried out. We reconstructed the duodenojejunostomy using the Roux-en-Y technique to separate the passage of food from the pancreas graft to prevent injury to other organs due to exposure to pancreatic secretions. Thereafter, we inserted a decompression tube into the anastomosis thorough the blind end of the jejunum. Finally, we inserted 3 drainage tubes for lavage. Following this procedure, the patient recovered gradually and no longer required hemodialysis and insulin therapy. She was discharged from our hospital 56 days after transplantation. ConclusionThe restoration of the injured graft was possible by management of pancreatic secretions and use of the donor's vessel grafts. Shortage of donors is a problem throughout the world; thus, it is important to use injured grafts for transplantation if possible.

Preoperative evaluation of moyamoya spontaneous anastomosis of combined revascularization donor vessels in adults by duplex ultrasonography

Objective: To evaluate the preoperative diagnostic value of duplex ultrasonography in moyamoya spontaneous anastomosis of combined revascularization donor vessels in adults.Methods: A total of 99 preoperative adult patients who underwent superficial temporal artery-to-middle cerebral artery (STA-MCA) anastomosis were retrospectively analyzed. Each side of the cerebral hemisphere was examined as a separate procedure. A total of 198 cerebral hemispheres were divided into three groups: a collateral, non-collateral, and control group based on digital subtraction angiography (DSA). Hemodynamic parameters, including peak systolic velocity (PSV), end diastolic velocity (EDV), and resistance index (RI) were analyzed.Results: There were only four of cases (5%, 4/198) of STA spontaneous anastomosis, whereas those of maxillary artery (MA) anastomosis were 44 (23.7%, 44/186). Compared with the control group, MA PSV and EDV of the collateral group increased significantly, while RI decreased significantly (p < .05). The area under the curve (AUC) of MA RI was 0.654. As a predictor of MA spontaneous anastomosis, duplex ultrasonography had high specificity but poor sensitivity. In collateral group, PSV and EDV detected two weeks post-surgery were significantly higher than those detected pre-operatively (PSV: p = .018, EDV: p = .025). By contrast, there were no significant difference of the PSV and EDV detected six months post-surgery compared with pre-operation (PSV: p = .450, EDV: p = .099). Additionally, MA RI in two weeks after the surgery was comparable with preoperative values.Conclusions: Duplex ultrasonography could be applied to evaluate the adult moyamoya spontaneous anastomoses of MA preoperatively. Despite its poor sensitivity, this diagnostic modality is still reliable and specific. STA-MCA anastomosis combined with EDMS did not affect MA pre-operative spontaneous anastomosis.

Microsurgical anatomy of the maxillary artery for extracranial-intracranial bypass in the pterygopalatine segment of the maxillary artery.

The extracranial-intracranial (EC-IC) bypass using the maxillary artery (MA) has been successfully completed using a radial artery (RA) graft but the complicated anatomy and narrow exposure make it difficult. The purpose of this article is to define the microsurgical exposure of the MA through the middle fossa and describe the branches, diameter, and length of the MA available for the EC-IC bypass in the sphenopalatine fossa and anterior part of the infratemporal fossa. 5 cadaveric specimens were dissected bilaterally (10 MA dissections) to define the microsurgical anatomy of the MA through an intracranial approach. The exposable branches of the MA at the level of the infratemporal and sphenopalatine fossae were the anterior deep temporal, posterior superior alveolar, and infraorbital arteries. The origin of each branch could be exposed. The available section of the MA for use as a donor vessel is between the origin of the anterior deep temporal artery and the infraorbital artery. The mean exposable length of the MA was 19.4 mm. The mean outer diameter of the donor MA was 3.2 mm. Tension-free EC-IC bypass was possible using a RA graft between the MA and the middle cerebral artery, the MA and the supraclinoid internal carotid artery (ICA), or the MA and the petrous ICA. Exposure of the MA at the infratemporal and sphenopalatine fossae is complicated but provides length and diameter suitable as a donor artery for the EC-IC bypass. Clin. Anat. 31:724-733, 2018. © 2017 Wiley Periodicals, Inc.

The Middle Temporal Artery: Surgical Anatomy and Exposure for Cerebral Revascularization.

The middle temporal artery (MTA) is the proximal medial branch of the superficial temporal artery (STA), supplying the temporalis muscle along with deep temporal arteries. Its use in vascularized flaps for reconstructive and otologic procedures has been described, yet its potential use in neurosurgery has not been studied. We report a novel technique for exposing the MTA and evaluated its characteristics for extracranial-intracranial cerebrovascular bypass. After a curvilinear frontotemporal incision in 10 cadaveric specimens, the STA was dissected from distal to proximal. The horizontal portion of MTA was found posterolateral to the posterior end of the zygomatic root and was followed proximally until its origin and distally until its 2 terminal branches. The total length, visible branches, and caliber of MTA were measured. The mean total harvested length of MTA was 31.7 ± 5.1 mm, with an average proximal caliber of 1.7±0.4 mm, and distal caliber of 1.3 ± 0.5 mm. There were 4-6 terminal MTA branches. The caliber of the proximal STA trunk was 2.5 ± 0.5 mm. The origin of the MTA was visible with a mean distance of 16.9 ± 4.8 mm inferior to the PEZR. The parotid gland was traversed and a communicating auriculotemporal nerve to the temporal branch of the facial nerve crossed MTA in 2 specimens. MTA can be safely harvested with an anterolateral approach, following its horizontal portion at the level of the zygomatic root, which is constant. The length and caliber of MTA makes it a potential alternative donor vessel or interposition graft for extracranial-intracranial bypass, especially when other donors are unavailable.

A vascularized preputial free flap for labial reconstruction in a dog.

To describe the clinical application of a vascularized preputial free flap in the reconstruction of a large facial-labial defect. Case report. An adult neutered male mongrel dog with a large left facial-labial defect. A preputial free flap was created by elevating the cranial part of the prepuce, using the ipsilateral caudal superficial epigastric vessels as a vascular pedicle. The flap was transferred to the facial-labial defect and the donor vessels anastomosed to the sublingual artery and vein, using standard microvascular technique. The free flap survived, leading to good cosmetic and functional outcomes. No major complications were encountered at either the donor or recipient sites after 2 years of follow-up. Vascularized preputial free flaps can be used to manage composite facial and oral cavity defects involving large areas of skin and mucosa.

Microsurgical refinements with the use of internal mammary (IM) perforators as recipient vessels in transverse upper gracilis (TUG) autologous breast reconstruction.

The transverse upper gracilis (TUG) flap is the senior authors' second choice for autologous breast reconstruction when the DIEP flap is not available. It provides durable, pliable tissue with well hidden scars. The main criticism of this flap is the limited volume, donor site complications, short pedicle and vessel mismatch depending on which recipient vessels are used. We described methods of reducing vessel mismatch, complications of venous coupler and refinements to help give a more superior aesthetic outcome. We describe several maneuvers to help reduce vessel mismatch with the use of the internal mammary (IM) perforator vessels with a modification of the Harashina fish-mouth technique or the use of a vessel bifurcation to increase vessel diameter. We also describe the optimum method of perforator preparation and potential methods to prevent palpable venous couplers. The author's describe their case series of 14 TUG flaps to reconstruct 13 breasts in 12 patients. Eight unilateral, 2 partial breast reconstruction, 1 bilateral and 1 bilateral TUG flap for a unilateral reconstruction was carried out. All flaps survived with one partial flap necrosis, one donor site seroma and two cases of palpable/tender venous couplers. The mean reconstructed breast was 320 grams. The TUG flap is a reconstructive challenge, but with correct planning a good aesthetic outcome is possible. The IM perforator is our first choice recipient vessel in TUG breast reconstructions. With meticulous preparation and by overcoming vessel mismatch the use of this recipient vessel is a reliable option.

24 The physiological impact of coronary chronic total occlusion (cto) percutaneous coronary intervention (pci) on donor vessel coronary pressure-derived measurements and the influence of collateral circulation

BackgroundThere is strong evidence of FFR guided treatment in multi-vessel disease. Multi-vessel disease is present in up to 66% of patients with CTO in a large registry analysis. The presence...

23 The influence of collateral regression post coronary chronic total occlusion (cto) percutaneous coronary intervention (pci) on donor vessel coronary pressure-derived measurements

Background There is strong evidence of FFR guided treatment in multi-vessel disease. The presence of a concomitant CTO may influence the FFR measurement in donor vessel as suggested in previous studies and reports. This has an important implication on clinical decision making for complete revascularisation in patients with chronic total occlusion. We sought to investigate the influence of collateral regression after successful CTO recanalisation on donor vessel pressure-derived indices. Methods The study participants were patients with angina who had RCA CTO. 28 out of 34 consecutive patients underwent successful PCI to RCA CTOs during the study period and completed the follow study (at 3 months post CTO PCI) were included in this analysis. Coronary pressure-derived indices (resting PD/PA, iFR and FFR) were measured pre and post successful RCA CTO PCI in donor vessels and at follow up procedures. Results The mean age was 62.38 years. The mean estimated CTO duration was 238.72 weeks and CTO length was 32.44 mm. 25 patients had ischaemia and or viability in the RCA territory assessed with cardiac MRI. LAD was the major donor vessel in 24 patients and LCX was the minor donor vessel in 4 patients. Percent stenosis on QCA in the major and minor donor vessel were 40.6% and 35.1% respectively. The mean resting Pd/Pa, iFR and FFR pre and post RCA CTO PCI and at follow-up procedures in major donor vessel were (0.893, 0.862, 0.764), (0.907, 0.886, 0.753) and (0.918, 0.901, 0.787) respectively. The mean resting Pd/Pa, iFR and FFR pre and post RCA CTO PCI and at follow-up procedures in minor donor vessel were (0.979, 0.966, 0.890), (0.983, 0.979, 0.880) and (0.981, 0.974, 0.898) respectively. The changes in coronary pressure-derived indices pre and post RCA CTO PCI and at follow up procedures are summarised in table 1. In major donor vessel, there was significant changes in the difference between follow up and pre-CTO PCI values for Pd/Pa, iFR and FFR values (p values 0.006, 0.003 and 0.047 respectively). There was also significant change in the difference between follow up and post-CTO PCI FFR value (P value 0.002). FFR collateral reduced significantly at follow-up (p value 0.000). Conclusion Successful recanalisation of a RCA CTO results in increase in major donor vessel coronary pressure-derived indices at follow up procedure associated with the regression of collateral function. In patients with multi-vessel disease, the expected change and the optimal timing to perform PCI in donor vessel should be considered when planning multi-vessel revascularisation in this setting.

Outcomes of Isolated Pediatric Small Intestine Transplants Using Vascular Homografts

Introduction: Pediatric intestinal transplantation has changed recently with more isolated small intestine transplants being performed in small children instead of combined liver-intestine transplants. Consequently, surgical techniques have changed, requiring a frequent use of vascular homografts of small caliber, the impact of which on outcomes is unknown. Methods: Among 106 pediatric intestine and multivisceral transplants performed at our center since 2003, 39 recipients of an isolated small intestine graft were reviewed. Four patients transplanted between 2003 and 2005 with insufficient medical records and two patients with follow-up <1 year were excluded. The remaining 33 pts, including 4 retransplants (16M, 17F, median age 3.3 y [range 1.2-17.2], median weight 14.2 kg [8.1-56]) were included in this study. Grafts were monitored with Doppler of the stoma and angiography when necessary. Patients with hypercoagulable state received systemic anticoagulation from the time of graft reperfusion. Outcome parameters were thrombotic complications and graft survival. Results: 25/33 grafts (76%) were reperfused “centrally” (aorta and vena cava), 24 of them via vascular homograft. The other 8 grafts were reperfused via native superior mesenteric artery and vein. Overall, 28/33 (85%) patients required both arterial and venous homografts from the same donor (donor's median age 1.1 y [2mo-23 y], median weight 10 kg [14.7-48.5]), mainly iliac or carotid artery and iliac or innominate vein, respectively. Post-transplant, there were 3 acute thromboses at the anastomosis of the arterial homograft (2 central and one mesenteric) on post-operative day 0, 2 and 13 and one venous homograft thrombosis on POD 7 requiring urgent percutaneous thrombolysis and/or operative thrombectomy resulting in 2 peri-operative graft salvages and 2 graft losses. Three out of 4 thromboses occurred in patients with primary hypercoagulable state, including the 2 graft losses. Overall, at a median of 4.1 years (1–10.2) from transplant, 29/33 (88%) patients are alive with 26/33 (79%) functioning grafts. Conclusion: In our series 2/33 (6%) pediatric isolated intestine grafts were lost due to thrombotic complications of the vascular homograft in patients with hypercoagulable state. The procurement of intact, size-matched donor vessels and post-transplant anticoagulation are critical.

A Mouse Model of Vascularized Skin Transplantation.

Allogeneic skin tissues are highly antigenic and induce intensive immune rejection after composite tissue allotransplantation. Mouse models have advantages in mechanistic studies of immune rejection. However, due to technical challenge in vascular anastomosis with suture technique, mouse vascularized skin allotransplantation models are not widely used in studies of immune rejection. Therefore, the authors propose vascular anastomosis through cuff technique during allotransplantation of mouse donor free groin skin flaps to either recipient inguinal or cervical site. Free groin skin flaps from BALB/c or C57BL/6 donor mice were transplanted to the groin (inguinal vascularized skin transplantation [IVST]) or to the neck of recipient sites (cervical vascularized skin transplantation [CVST]) of C57BL/6 mice. A nonsuture cuff technique was utilized to anastomose the donor vessels with either femoral vessels in IVST recipients or common carotid arteries and external jugular veins in CVST mice. Immunosuppressant drugs were used in the allogeneic skin group. The overall success rate was higher in the CVST (88.5%) when compared with the IVST (78.9%). Total operation time in CVST mice lasted 96 minutes (95% confidence interval, 92-101 minutes) that was shorter than that for IVST mice (136 minutes, 95% confidence interval, 127-176 minutes; P < 0.01). Complications, such as hindlimb necrosis and self-mutilation, were observed in IVST mice. Rapamycin (3 mg/kg, daily) significantly prolonged vascularized skin allografts survival with median survival time of 80 days. All syngeneic grafts survived for more than 80 days. We developed a novel mouse vascularized skin transplantation model that is feasible for the study of clinically relevant skin rejection and tolerance.

Impact of Collateral Circulation on Survival in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention With a Concomitant Chronic Total Occlusion

ObjectivesThis study sought to compare long-term clinical outcome in ST-segment elevation myocardial infarction (STEMI) patients with a concomitant chronic total occlusion (CTO) with well-developed versus poorly developed collaterals toward the CTO. BackgroundIn STEMI patients, presence of a CTO is associated with increased morbidity and mortality. CTOs are often (partially) perfused by collateral vessels. Therefore, when the infarct-related artery (IRA) is the main donor vessel for the collateral blood supply of the CTO, infarct size may increase significantly. Well-developed collaterals to the infarct related vessel have been associated with improved clinical outcome after STEMI. However, the impact of well-developed collaterals toward a concomitant CTO in STEMI patients is unknown. MethodsConsecutive STEMI patients with a CTO in a non-IRA presenting for primary percutaneous coronary intervention (PCI) were divided according to the presence of angiographic, well-developed (grade 2 to 3) or poorly developed collaterals (grade 0 to 1). ResultsBetween 2000 and 2012 we included 413 STEMI patients with a single concomitant CTO. Well-developed collaterals to the CTO were present in 53%. Associated with poorly developed collaterals to the CTO were cardiogenic shock (hazard ratio [HR]: 1.8; 95% confidence interval [CI]: 1.11 to 3.07; p = 0.02), CTO located in the left circumflex artery (HR: 1.9; 95% CI: 1.00 to 3.43; p = 0.05), CTO diameter ≤2.5 mm (HR: 2.1; 95% CI: 1.07 to 4.12; p = 0.03), and CTO tapering (HR: 1.9; 95% CI: 1.21 to 2.85; p < 0.001). Patients with well-developed collaterals to the CTO had a better 5-year survival compared to those with poorly developed collaterals (74% vs. 63%; p = 0.01). The presence of well-developed collaterals to the CTO was independently associated with improved survival (HR: 1.5; 95% CI: 1.03 to 2.10; p = 0.04). ConclusionsIn STEMI patients with a CTO in a non-IRA, the presence of well-developed collaterals to the CTO is associated with improved survival.

The retrospectively analysis of risk factor with free transplanted compound tissue necrosis

Objective To analyse the risk factor of vascular crisis following free compound tissue transplantation in order to avoid the risk factor and improve the survival rate of free compound tissue. Methods Sixteen patients with free compound tissue transplantation were retrospectively reviewed between June, 2010 and December, 2015. The age, sex, injury reason, operation time, injury site and donor vessel of the patients were recorded and analysed.The risk factors of free transplanted compound tissue necrosis were concluded. Results Of 16 cases, 5 cases were anterolateral thigh flap, 4 cases medial peroneal artery flap, 2 cases osteocutaneous flap, 1 case toe transplantation, 1 case medial plantar artery flap, 1 case forearm reverse interosseous posterior artery flap and 1 case groin flap. In 16 patients with free compound tissue transplantation, there was no difference in sex and age (P>0.05) . The percentage was higher in the patients injured by vehicle than the patients injured by non-vehicle (P<0.05) . The percentage was lower in the patients with operation within 4 weeks after wound than beyond 4 weeks (P<0.05) .Transplanted tissue necrosis was prone to appear in the patients with low limb injury. The incidence of transplanted tissue necrosis was higher in low limb than in upper limb, and the highest in foot (P<0.05) . If the donor vessel was the dorsalis pedis artery, anterior tibial artery or posterior tibial artery, the incidence of transplanted tissue necrosis was very high. The highest rate was the dorsalis pedis artery (P<0.05) . Conclusion Injury by vehicle, surgery happening beyond 4 weeks after wound and injury in low limb were the high risk factor of tissue necrosis following free compound tissue transplantation. Key words: Surgical flap; Vascular crisis; Necrosis; Risk factor; Retrospectively analusis

The maxillary artery and its variants: an anatomical study with neurosurgical applications.

The maxillary artery (MA) has gained attention in neurosurgery particularly in cerebral revascularization techniques, intracranial endonasal approaches and endovascular procedures. To describe and illustrate the anatomy of the MA and its neurosurgical importance in a detailed manner. Six cadaveric heads (12 MAs) were injected with latex. The arteries and surrounding structures were dissected and studied using microsurgical techniques. The dimensions, course and branching patterns of the MA were recollected. In addition, 20 three-dimensional reconstruction CT head and neck angiograms (3D CTAs) of actual patients were correlated with the cadaveric findings. The MA can be divided in three segments: mandibular, pterygoid and pterygopalatine. Medial and lateral trunk variants regarding its course around the lateral pterygoid muscle can be found. The different branching patterns of the MA have a direct correlation with the course of its main trunk at the base of the skull. Branching and trunk variants on one side do not predict the findings on the contralateral side. In this study the highly variable course, branching patterns and relations of the MA are illustrated and described in human cadaveric heads and 3D CTAs. MA 3D CTA with bone reconstruction can be useful preoperatively for the identification of the medial or lateral course variants of this artery, particularly its pterygoid segment, which should be taken into account when considering the MA as a donor vessel for an EC-IC bypass.

Focused Arterial Anastomotic Assessment in a Novel Univariate Design of a Vertical Rectus Abdominis Muscle Flap in a Pig Model

Background Microsurgical anastomosis is the basis for free tissue transfer. The goal of this study was to create an animal model that mimics free tissue transfer but would focus on the arterial anastomotic assessment alone, without additional bias of a venous anastomosis. Methods A vertical rectus abdominis musculocutaneous (VRAM) flap based on the left deep superior epigastric artery (DSEA) was raised in six large white pigs. The right DSEA was raised and used as the donor vessel. An arterial end-to-end microsurgical anastomosis was then performed between the right and the left SEA artery. The lateral deep epigastric vein (DIEV) was left intact to drain the flap. Perfusion of the flap was confirmed clinically by laser Doppler and by flowmetry. Results One flap failure was observed in this study that occurred on postoperative day (POD) 5 as a consequence of venous occlusion due to hematoma. There was a significant initial drop in arterial flow across the anastomosis in comparison to preanastomotic flow measurements (p &lt; 0.05); however, this was normalized by the seventh POD (p &gt; 0.05). Flow measurements in the vein significantly increased after the arterial anastomosis was completed and the seventh POD (p &lt; 0.05). Laser Doppler assessment demonstrated adequate tissue perfusion of the skin island flap. Conclusion This modified VRAM flap is a viable procedure to simulate a free flap transfer and assess the arterial anastomosis alone, while maintaining the flap's innate venous drainage. This method can allow the investigation of new arterial anastomosis techniques and devices.

The "11 O'clock Heel First" technique for microvascular end-to-side anastomosis.

The heel of a microvascular end-to-side anastomosis is a common site for technical imperfections. We describe a simple technique to overcome this challenge. The aim of the technique is to insert all the sutures in an inside-to-outside manner at the heel area on the donor side of the anastomosis. This technique has first been tested in a laboratory setting and then was further elaborated in a clinical setting. One hundred and twenty adult albino Wistar rats of both genders were randomized into the following two groups: (A) Control, 48 rats, representing approximately 40% of the total sample, underwent the usual two anchoring stitch technique; (B) Study group, 72 rats, representing approximately 60% of the total sample, underwent the technique described. Patency was confirmed both clinically and by the use of fluorescein angiography. Rat weight, diameter of both the donor and recipient vessels, type of anastomosis (arterio-arterial or arterio-venous) and angiographic findings were used as variables. A P value of less than 0.05 was considered significant. The proposed technique had increased patency rates as compared to the standard technique, which was statistically significant (P = 0.021). However, there was no difference between the patency rates of arterio-arterial and arterio-venous atastomoses. The proposed technique is useful for perfecting the heel area of a microvascular end-to-side anastomosis in both laboratory and clinical settings.

Arterial and venous coupling by microvascular anastomotic coupling device in head and neck reconstruction

Objective To assess the value of using microvascular anastomotic coupling device(MACD) in head and neck reconstruction, especially in arterial coupling. Our experience was summed up to improve the success rate of anastomosis. Methods This research had enrolled all patients performed free flap reconstruction in our department from January, 2015 to Auguest, 2016. The data were obtained on type of free flap, donor and recipient vessels, type of MACD, time of anastomosis and so on. Results 169 patients were included in this study. Free flap reconstructions were done by manual suture in 25 patients and MACD in 144 patients. Coupling the arteries and veins by MACD[(5.7 ± 1.2)min and (5.1 ± 1.0) min, respectively] had taken less time than manual suture[(21.4 ± 3.1)min and (23.2 ± 4.2)min, respectively]. 223 MACD were used totally to couple 44 arteries and 179 veins. There was no significant statistical difference in vascular crisis and flap survival between manual suture and MACD(P > 0.05). One arterial crisis (2.3%) and on flap loss was found in the patients coupling arteries by MACD. Conclusion MACD is a optimal method for coupling veins of free flap in head and neck reconstruction, because of high success rate and shortening surgery time. As well MACD can be a important option in arterial anastomosis after appropriate vessels choosing and pretreatments. Key words: Microvascular anastomotic device; Head and neck; Reconstruction; Surgical flap; Arterial anastomosis

Histopathological features of middle cerebral artery and superficial temporal artery from patients with moyamoya disease and enlightenments on clinical treatment.

The histopathological features of the middle cerebral artery (MCA) and superficial temporal artery (STA) from moyamoya disease (MMD) and their relationships with gender, age, angiography stage were explored. The causes and the clinical significance of vasculopathy of STA were also discussed. The clinical data and specimens of MCA and STA from 30 MMD patients were collected. Twelve samples of MCA and STA from non-MMD patients served as control group. Histopathological examination was then performed by measuring the thickness of intima and media, and statistical analysis was conducted. The MCA and STA specimens from MMD group had apparently thicker intima and thinner media than those from the control group. There was no significant pathological difference between the hemorrhage group and non-hemorrhage group, and between the males and females in MMD patients. Neither the age nor the digital subtraction angiography (DSA) stage was correlated with the thickness of intima in MCA and STA. MMD is a systemic vascular disease involving both intracranial and extracranial vessels. Preoperative external carotid arteriography, especially super-selective arteriography of the STA, benefits the selection of donor vessel.

REMOVED: Liver autotransplantation and retrohepatic vena cava reconstruction for alveolar echinococcosis

Alveolar echinococcosis (AE) is characterized by a slow-growing infiltrative neoplasm that is often unresectable by traditional methods because of strong adhesions and invasion to adjacent structures. We present our experience with liver autotransplantation and retrohepatic inferior vena cava (RHIVC) reconstruction using autogenous veins in patients with this end-stage parasitic disease. Twelve patients with hepatic AE and extensive RHIVC, hepatic vein, and/or hilar invasion underwent exvivo liver resection and RHIVC reconstruction using autogenous veins followed by autotransplantation in the West China Hospital of Sichuan University from 2013 to2016. The mean weight of the harvested liver graft was 537g (range: 390-900g), the mean anhepatic time was 216min (range, 120-310min), and the mean operation time was 13.6h (range, 10.5-19.5h). The main postoperative complication was bile leakage. The mean postoperative hospital stay was 16.4d (range, 10.0-37.0d), and the median follow-up time was 15.5mo (range, 1.0-32.0 mo). All patients were alive at the latest follow-up. The vascular patency rate was 100%, and no residual disease, recurrence, or metastasis was detected. To our knowledge, liver autotransplantation and RHIVC reconstruction using autogenous veins are rarely performed for patients with end-stage hepatic AE. This technique requires no organ donor, allogeneic, or artificial vessel implantation, postoperative immunosuppressive therapy, or long-term postoperative anticoagulant treatment. These benefits may make the treatment of select end-stage hepatic AE patients more affordable and effective.

Non-HLA-matched 3rd party vascular allograft in renal transplant may lead to sensitization against donor HLA.

3rd party donor vessels are often used for vascular reconstruction in organ transplantation. While current practice ensures that 3rd party vessels are blood group matched, HLA matching to the non-intended recipient is not performed. This practice potentially sensitizes the recipient and may reduce their future chance of renal transplant from a larger pool of donors. We examined our cohort of renal transplant recipients who received non-HLA-matched 3rd party vessels for the de-novo development of donor-specific HLA antibodies. Our institution's Human Tissue Authority (HTA) blood vessel registers were examined to identify stored donor vessels and their non-intended recipients. Donor vessel HLA status was cross-referenced with the recipient HLA status. Between 2004 and 2014, five patients were identified that received 3rd party non-HLA-matched vessels for vascular reconstruction during renal transplantation. Three patients (60%) subsequently developed donor-specific HLA antibodies. These data provide evidence that use of non-HLA-matched stored 3rd party vascular grafts may lead to sensitization in the recipient. Where time permits, HLA matching should be performed to avoid this allogeneic response. Laboratories monitoring DSA should be aware of any patient receiving a non-HLA-matched 3rd party vascular graft, and recipients may benefit from increased post-transplant immunological vigilance.

Use of Distal Medial Sural Vessels as Recipient Vessels in Free Tissue Transfer.

Background The medial sural vessels have been used extensively as donor vessels in free tissue transfer; however, there is sparse literature detailing their use as recipient vessels. The few existing reports involve small numbers of patients and describe operative approaches that are unnecessarily cumbersome. We explored our experience in free tissue transfer to the medial sural vessels and share a simplified operative approach to this recipient site. Methods A retrospective review was performed of all patients who underwent free tissue transfers to the medial sural vessels between December 2012 and December 2015 at a single institution. Preoperative imaging, operative approach, and technique for microvascular free tissue transfer to the medial sural vessels were reviewed. Postoperative results and complications were also analyzed. Results Using preoperative magnetic resonance angiography (MRA) to image the medial sural vessels and a retrograde perforator dissection technique, we successfully performed free tissue transfer to the distal medial sural vessels in 20 of 21 patients, representing the largest series reported. Postoperatively, 13 of 21 patients underwent MRA with a patent vascular pedicle demonstrated in all. There were no postoperative complications or resultant morbidities. Conclusion Surgeons should be aware of the medial sural vessels as a valuable recipient option for free tissue transfer to the lower extremity.