Double Vein Research Articles

Transfemoral hepatic vein access in double vein embolization – initial experience and feasibility

BackgroundHepatic vein embolization in double vein embolization (DVE) can be performed with transhepatic, transjugular or transfemoral access. This study evaluates the feasibility and technical success of using a transfemoral access for the hepatic vein embolization in patients undergoing preoperative to induce hypertrophy of the future liver remnant (FLR).Material and methodsRetrospective analysis of single center cohort including 17 consecutive patients. The baseline standardized FLR was 18.2% (range 14.7–24.9). Portal vein embolization was performed with vascular plugs and glue through an ipsilateral transhepatic access. Hepatic vein embolization was performed using vascular plugs. Access for the hepatic vein was either transhepatic, transjugular or transfemoral. Technical success, number of hepatic veins embolized and complications were registered. In addition, volumetric data including degree of hypertrophy (DH) and kinetic growth rate (KGR), and resection data were registered.R: Seven of the 17 patients had transfemoral hepatic vein embolization, with 100% technical success. No severe complications were registered. In the whole cohort, the median number of hepatic veins embolized was 2 (1–6). DH was 8.6% (3.0–19.4) and KGR was 3.6%/week (1.4–7.4), without significant differences between the patients having transfemoral versus transhepatic /transjugular access (p = 0.48 and 0.54 respectively). Time from DVE to surgery was median 4.8 weeks (2.6–33.9) for the whole cohort, with one patient declining surgery, two having explorative laparotomy and one patient having change of surgical strategy due to insufficient growth.ConclusionTransfemoral access is a feasible option with a high degree of technical success for hepatic vein embolization in patients with small future liver remnants needing DVE.

CIRSE Standards of Practice on Portal Vein Embolization and Double Vein Embolization/Liver Venous Deprivation

This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing liver regeneration therapies prior to major hepatectomies, including portal vein embolization, double vein embolization and liver venous deprivation. It has been developed by an expert writing group under the guidance of the CIRSE Standards of Practice Committee. It encompasses all clinical and technical details required to perform liver regeneration therapies, revising the indications, contra-indications, outcome measures assessed, technique and expected outcomes.

Transfemoral hepatic vein catheterization reduces procedure time in double vein embolization

BackgroundDouble vein embolization with simultaneous embolization of the portal and hepatic vein aims to grow the future liver remnant in preparation for major hepatectomy. Transvenous hepatic vein embolization is usually done via a transjugular access. The purpose of this study is to describe the transfemoral approach as an alternative option and to discuss potential advantages.ResultsTwenty-three patients undergoing hepatic vein embolization via a transjugular (n = 10) or transfemoral access (n = 13) were evaluated retrospectively. In all cases the portal vein embolization was done first. All procedures were technically successful. There were no peri-interventional complications. Only two patients were not able to proceed to surgery. Standardized future liver remnant hypertrophy was non-inferior with the transfemoral approach compared to the transjugular route. Procedure time was significantly shorter in the transfemoral access group (40 ± 13 min) compared to the transjugular group (67 ± 13 min, p < 0.001).ConclusionTransfemoral hepatic vein embolization is feasible, safe, and faster due to easier catheterization, improved stability, and simpler patient preparation. These findings will need to be validated in larger studies.

Single-Center Retrospective Study Comparing Double Vein Embolization via a Trans-Jugular Approach with Liver Venous Deprivation via a Trans-Hepatic Approach.

To compare safety, technical and clinical outcomes of double vein embolization (DVE) via a trans-jugular approach with liver venous deprivation (LVD) via a trans-hepatic approach. A single-center retrospective analysis was conducted on patients undergoing simultaneous portal and hepatic veins embolization in view of a major hepatectomy (June 2019-November 2022). Hepatic vein embolization was performed either by transjugular plug (DVE) or by transhepatic plug followed by glue injection (LVD). Inclusion criteria were availability of pre-procedural CT scan, and availability of CT scans acquired 10days and 25days post-procedure. Comparative data included complication rate, fluoroscopy time, dose area product (DAP), Future Liver Remnant volume and function increase (FLR-V and FLR-F increase, respectively) and clinical outcomes. Thirty-six patients (n = 14 DVE; n = 22 LVD) were included. No baseline significant differences were observed among the two groups. One grade-3 complication (2.8%) was observed in the LVD group; one case of technical failure (2.8%) was observed in the DVE group. Fluoroscopy time and DAP were similar between DVE and LVD (29 ± 17.7 vs. 25 ± 8.2min, p = 0.97; 105.1 ± 63.5 vs. 143.4 ± 79.5Gy·cm2, p = 0.15). No differences arose at either time-point in FLR-V increase (46.7 ± 23.1% vs. 48.2 ± 28.2%, 52.9 ± 30.9% vs. 53.2 ± 29%, respectively, p = 0.9). FLR-F increase also did not differ significantly (62.8 ± 55.2 vs. 67.4 ± 57.5, p = 0.9). No differences in drop-out rate from surgery were observed. (28.6% vs. 27.3%, p = 0.93). One case of grade-B post-hepatectomy liver failure (2.8%) was observed in the LVD group. LVD via transhepatic approach and DVE via transjugular approach seem equally safe and effective. Level of Evidence Level 3, Retrospective Cohort Study.

Intravascular Ultrasound in Treating Iliac Vein Compression With Endovascular Stenting: A Necessary Tool for Optimal Outcomes.

Symptomatic compression of the left common iliac vein between the right common iliac artery and spinal vertebrae is referred to as May-Thurner Syndrome (MTS). Atypical cases of MTS including compression of the left external iliac vein, right iliac vein or the inferior vena cava can also coexist and cause double vein compression. Current literature suggests that endovascular treatment including thrombolysis, thrombectomy, venoplasty and stent placement to correct the mechanical obstruction together with anticoagulation therapy is safe and a reasonable management for patients with MTS. Intravascular ultrasound (IVUS) can aid in the diagnosis and the operative planning of MTS, especially regarding sizing and precise deployment of venous stents. Here we present 2 unique atypical cases of MTS with double left iliac vein compression treated endovascularly with stent placement along the common and external iliac vein with the assistance of IVUS.

Optimization of Vascular Supply in Free Flaps for Head and Neck Reconstruction: Analysis of a Young Team’s Experience

BackgroundFor head and neck reconstructive procedures, free flap survival depends on microsurgical and anatomical choices besides multimodal clinical management. The aim of the present study is to identify relevant variables for flap survival in our initial consecutive series.MethodsA single-center, novel reconstructive team consecutive surgical series was revised. The outcome was analyzed in terms of flap survival observing variables considered more relevant: flap type, recipient artery, vein(s), and graft interposition were discussed for facial thirds to be reconstructed. Statistical analysis was performed with Chi-square, Mann–Whitney, and Odds ratio.ResultsA total of 118 free flaps were performed in 115 microsurgical procedures (93.9% for malignancies) on 109 patients, with a flap survival rate of 91.5%. For reconstruction of the middle and lower third of the face, the facial artery was privileged, because it was already transected during lymph node dissection in order to save the superior thyroid artery for further microsurgical needs. Flap failure was 50% venous. Double vein anastomosis was not related to flap survival. Deep venous drainage (as the internal jugular vein system) required fewer revisions. Half of the re-explorations saved the flap. Grafts were a risk for flap survival. Bony flaps were more critical.ConclusionAt comparable reconstructive quality, flap choice should avoid a vascular graft. The facial artery is a preferable recipient vessel, since it saves other arteries both in the case of an arterial revision and in the case of recurrence, for further free flap reconstruction. For venous anastomosis, a deep venous recipient is safer, since it offers the possibility to choose the level of anastomosis optimizing the vascular pedicle geometry. A close postsurgical flap monitoring is advisable up to 7 days postoperatively to allow for timely flap salvage.

Anatomical variations of dominant anastomotic veins in the superficial cortical venous system

BackgroundUnderstanding the anatomy of the anastomotic veins (AV) of the superficial cortical venous system (SCVS), viz. Superficial Sylvian vein (SSV) - also known as the superficial middle cerebral vein; vein of Labbe (VL) and vein of Trolard (VT), are imperative for neurosurgical procedures. This study aimed to investigate variant anatomical patterns of dominance of the AV, to elucidate the haemodynamically balanced SCVS, by reporting variations between the presence, diameter and dominant patterns of the AV. MethodsTwo hundred lateral angiograms were included, depicting left and right cerebral hemispheres of the same patient (n = 100 patients). Angiograms were analysed and variations recorded. Results were statistically compared against laterality, age, sex and ethnicity. ResultsPresence of the VL had the highest occurrence (96.5%), whereas the SSV and VT had an occurrence of 75.5% and 64.5%, respectively. This study reports presence of double veins of the AV: SSV (12.0%), VL (22.0%) and VT (19.5%). Furthermore, presence of a triple vein for each AV is reported. Diameters for the SSV, VL and VT were 1.99 ± 0.500 mm, 2.18 ± 0.579 mm and 2.14 ± 0.472 mm, respectively. Statistically significant relationships were established between diameters and the SSV, VL, VT and VT2 (double VT). Seven types of dominant patterns were recorded: Equilibrium; singular dominance of SSV, VL and VT; co-dominance of SSV/VL, SSV/VT and VL/VT. The Equilibrium dominant pattern of drainage had the highest occurrence (54.5%). ConclusionPatterns of dominance of these AV can aid the neurosurgeon in curbing the risk of iatrogenic injury and postoperative infarcts even after an otherwise successful surgery.

The impact of a double vein anastomoses on doppler's loss of signal rates

BackgroundImpact on blood flow by double vein anastomosis in head and neck free flaps is unclear. We aimed to assess venous doppler loss of signal (LOS) rates of double vein system compared with a single vein system. MethodsConsecutive free flaps with implanted venous flow couplers between 2015–2017 were included. LOS rates were compared between groups and with regard to flap type, defect site and recipient vein within double vein group. Results92 double-vein (184 veins) and 48 single-vein flaps were included. LOS was similar in single- and double-vein flaps (11/48 (25%) versus 46/184 (25%), p = 0.765). Double veins had fewer flap takebacks compared with single vein (4.3% vs. 12.5%, p = 0.075). Common facial vein (CFV) anastomosis showed superior LOS rates compared with external jugular and CFV branches (p = 0.026). ConclusionsDouble vein anastomosis does not impact LOS rates, results in fewer flap takebacks, yet LOS rates depend on selected recipient vein.

Radial Forearm Free Flap (RFFF) versus Anterolateral Thigh (ALT) Flap in Head and Neck Reconstruction

This is a prospective comparative study that aimed to compare two techniques for reconstruction of head and neck defects resulting from different causes in different ages, the radial forearm free flap (RFFF) and the anterolateral thigh flap (ALTF).setting: The plastic surgery department of Sohag University Hospitals.Patients and methods: For this purpose, 18 patients with head and neck defects were recruited from the attendants of the plastic surgery department, Sohag University Hospital during the period from January 2019 to January 2021 with head and neck defects of different causes and were divided into 2 groups; group A included 10 patients for whom an RFFF was done for reconstruction and group B ( 8 patients), for whom the free ALT flap was done to reconstruct their defects. Results: The mean age for the whole group (mean+ SD) was 42.7 + 27 years.However, patients in group A were significantly older than those in group B ( 59.1 +18.5 versus 22.5 + 20.9 years respectively, p < 0.001). The commonest cause was excision of malignant tumors (10 cases) followed by traumatic defects (7 cases) and 1 case of Romberg’s disease. The overall success rate was 72.2% (11 fully survived flaps and 1 case of peripheral necrosis) while 5 cases were lost to follow up (27.8%). The overall complication rate was 55.6% (10 cases): 70% (7 cases) in group A 37.5% (3 cases) in group B. The follow up period ranged from 6 months to 1 year for both groups. Conclusion: The RFFF is preferred in the elderly and the ALT in the younger age group with care of venous drainage either by a large caliber vein or double vein drainag.

Combined simultaneous embolization of the portal vein and hepatic vein (double vein embolization) \u2013 a technical note about embolization sequence

BackgroundSimultaneous portal vein embolization (PVE) and hepatic vein embolization (HVE) has been shown to be feasible, safe and lead to a faster growth of future liver remnant (FLR) than PVE alone. The objective of this study is to highlight different technical aspects as well as importance of embolization order.Materials and methodsSeven patients were treated with simultaneous PVE and HVE. In three cases, HVE was performed first followed by PVE and in four cases the other way around. Portal vein branches were embolized using Glubran-Lipiodol mixture in all cases. Hepatic veins were embolized using Amplatzer II plugs sized 8–20 mm. Specific consideration was given to depth of glue penetration in the portal vein defined by visible branch order on the treated side.ResultsSix of seven patients were discharged home the same day. One patient with infected tumor necrosis died of liver failure 40 days later, otherwise there were no periprocedural clinical complications. Median glue penetration was to the 5th order (4th – 5th) when PVE was performed first and 3rd order (2nd - 4th) when PVE was performed after HVE. In one PVE first case, glue spillage was seen due to marked reduced flow in the right portal vein. There was sufficient FLR growth for subsequent surgical resection in the remaining six patients.ConclusionPVE should be performed prior to HVE because the reduced flow in the portal vein after HVE leads to less deep glue penetration with presumably increased risk of contralateral spillage.

PD22-07 ROBOTIC ASSISTED KIDNEY TRANSPLANTATION: UPDATE FROM THE ERUS SERIES

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation & Vascular Surgery I (PD22)1 Apr 2020PD22-07 ROBOTIC ASSISTED KIDNEY TRANSPLANTATION: UPDATE FROM THE ERUS SERIES Mireia Musquera*, Tarek Ajami, Lluis Peri, Alberto Breda, Angelo Territo, Riccardo Campi, Sergio Serni, Volkan Tugcu, Selcuk Sahin, Karel Decaestecker, Philip Zeuschner, Micheal Stockle, Paolo Fornara, Nicolas Doumerc, Francesc Vigues, Ravi Barod, and Antonio Alcaraz Mireia Musquera*Mireia Musquera* More articles by this author , Tarek AjamiTarek Ajami More articles by this author , Lluis PeriLluis Peri More articles by this author , Alberto BredaAlberto Breda More articles by this author , Angelo TerritoAngelo Territo More articles by this author , Riccardo CampiRiccardo Campi More articles by this author , Sergio SerniSergio Serni More articles by this author , Volkan TugcuVolkan Tugcu More articles by this author , Selcuk SahinSelcuk Sahin More articles by this author , Karel DecaesteckerKarel Decaestecker More articles by this author , Philip ZeuschnerPhilip Zeuschner More articles by this author , Micheal StockleMicheal Stockle More articles by this author , Paolo FornaraPaolo Fornara More articles by this author , Nicolas DoumercNicolas Doumerc More articles by this author , Francesc ViguesFrancesc Vigues More articles by this author , Ravi BarodRavi Barod More articles by this author , and Antonio AlcarazAntonio Alcaraz More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000872.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic assisted kidney transplantation (RAKT) has recently been introduced in many centers in Europe with an important expansion over the last year, because of the good functional results that have been shown and the proved advantages of the minimally invasive surgery. From July 2015 till September 2019, 312 cases of RAKT have been performed in 10 European centers members of the ERUS-RAKT with favorable outcomes. The objective is to update the results of RAKT experience after 4 years since its introduction. METHODS: This is a multicenter prospective observational study of recipients who underwent RAKT. Descriptive analysis on recipients and donor characteristics, surgical data, intraoperative outcomes, complication rate and functional results were collected. RESULTS: A total of 312 RAKT have been performed, 21 (6.7%) of which were from cadaveric donors. Recipient’s characteristics were: male (65%), mean age 45.2 (SD 13.35) years, mean BMI of 27.13 (SD 19.28) kg/m2, and preemptive in 53% of cases. In 5 cases the graft was introduced through the vagina. Graft characteristics were: right kidneys (15.4%), multiple arteries (15.4%), double vein in 4 cases. In living donors mean warm ischemia time was 2.9 minutes (SD 2.2). Mean total surgical time was 244 min (SD 70.5), rewarming time 53.16 min (SD 15.27). Early complications were noticed: 5.7% have postoperative bleeding which was managed either conservatively (3 cases), transfusion (6), surgically (6) or by embolization (2) . Seven (2.4%) kidneys were lost and eventually explanted due to thrombosis (6 cases) and one acute rejection. 5 patients had delayed graft function. As for late complications, two patients had arterial stenosis, three incisional hernia and 6 ureteral stenosis treated either conservatively, endoscopically or repair. Nine lymphoceles were detected: 2 were managed conservatively, 2 by percutaneous drainage and 5 surgically. Neither surgical time nor rewarming time showed any correlation with post-operative creatining at 7th, 30th days and 1 year follow up (p>0,05). We compared the surgical data between the first 120 cases published in prior papers and the new ones; almost all surgical times were lower in the new cases group but only the total surgical time was significantly shorter. CONCLUSIONS: This is the largest European multicentric study on RAKT with good surgical and functional results competitive to the open technique, with a relatively short learning curve when it is done in centers with high experience in open kidney transplantation and robotic surgery. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e461-e461 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mireia Musquera* More articles by this author Tarek Ajami More articles by this author Lluis Peri More articles by this author Alberto Breda More articles by this author Angelo Territo More articles by this author Riccardo Campi More articles by this author Sergio Serni More articles by this author Volkan Tugcu More articles by this author Selcuk Sahin More articles by this author Karel Decaestecker More articles by this author Philip Zeuschner More articles by this author Micheal Stockle More articles by this author Paolo Fornara More articles by this author Nicolas Doumerc More articles by this author Francesc Vigues More articles by this author Ravi Barod More articles by this author Antonio Alcaraz More articles by this author Expand All Advertisement PDF downloadLoading ...

Double-vein (ore-bearing vs. ore-free) structures in the Xitian ore field, South China: Implications for fluid evolution and mineral exploration

Two types of spatially and temporally associated hydrothermal veins, ore-bearing and ore-free, occur as double vein structures in the Xitian ore field, South China. Here, we investigated the genetic relationship, material provenance, fluid properties, and prospecting significance of the co-developed veins in the granite-related, fault-controlled vein-type Xiangdong W, Goudanlan W, Chaling Pb–Zn and Xinggao fluorite deposits of the Xitian ore field, focusing on two common minerals: quartz and zircon. Petrographic, CL, microthermometric and H–O isotopic analyses of Stage I and Stage II quartz in both the ore-bearing and ore-free veins of these deposits document two episodes of hydrothermal activity. The first episode involved a high-temperature (up to 370 ℃), high-salinity (up to 28% NaCl equiv.), high-δ18O (–2.1‰ to +7.2‰), and high-δ2H (–82‰ to –54‰, mean = –68‰, n = 13) fluid that corresponds to the main magmatic-hydrothermal stage of the deposits, and the second episode involved a low-temperature (down to 90 ℃), low-salinity (down to 1% NaCl equiv.), low-δ18O (–8.8‰ to –5.3‰), and low-δ2H (–83‰ to –60‰, mean = –73‰, n = 6) fluid that represents an accessary mineralization stage. Variations in fluid inclusion types and compositions indicate that the processes of fluid mixing, boiling, cooling, and degassing played important roles in mineralization, and that magmatic fluid became less important than meteoric water along during the formation of ore-free veins. LA-ICPMS U–Pb dating reveals totally different age populations for these veins: zircons from the ore-bearing quartz veins yield older and more variable ages (pre-Devonian: >400 Ma, n = 68) that are similar to that of the local basement/sedimentary rocks, whereas zircons from the ore-free quartz veins yield younger and less variable ages (Triassic: 250–200 Ma, n = 31; and Jurassic: 170–140 Ma, n = 13) that are identical to those of the host granite zircons. In addition, the ore-free veins show lower temperatures, salinities, and total REEs (as recorded by quartz) but greater alteration (as reflected by CL and trace element features of hydrothermally-altered zircons) and wider vein size than the ore-bearing veins. We propose a “mineral–water separation” model to explain the formation of the double-vein structures. In this model, ore-bearing veins and ore-free veins formed in succession during faulting events: ore-bearing veins formed first in the smaller fractures and were the dominant sites of mineralization, whereas the ore-free veins served as dissipating passageways for residual water and silica in larger fractures. We suggest that the mineral-water separation model has good application prospects in mineral exploration, and that zircons can be applied as an indicative mineral to differentiate the mineralization potential of different types of quartz veins.

Cadaveric study of mode of termination of gonadal veins: Implications for procedures utilizing terminal ends of gonadal veins as entry portals

Context:The terminal ends of gonadal veins act as an entry portal in gonadal embolization procedures used for treating varicocele in males and pelvic congestion disease in females. Here, we studied the modes of termination of gonadal veins in adult cadavers.Materials and Methods:Thirty-five adult formalin-fixed cadavers (seventy sides) were studied over a period of 4 years. The modes of termination of gonadal veins were observed under the following study variables: (a) number, (b) locale of termination, and (c) termination angle.Results:Variations in study parameters were observed in eight sides of seven cadavers (seven unilateral and one bilateral). Double veins at termination were observed in six cadavers; anomalous termination was observed in three cadavers. Angle of termination differed from normal in 3 cadavers. In one of these cadavers, the left ovarian vein drained into the left suprarenal vein.Conclusion:Duplication of terminal ends, anomalous drainage site, and varied angles of termination call for caution to ensure the success of procedures, which use terminal ends of gonadal veins as entry portals.

How to deal with the vessel of free flap: A retrospective study of 264 cases of anterolateral thigh flap

Objective To compare the reliability and effectiveness of anterolateral thigh flap with double vein anastomosis or one vein anastomosis for reconstruction of head and neck defects. Methods Two hundred and sixty four cases of anterolateral thigh flap transfers for head and neck reconstruction from January, 2013 to September, 2013 in the Second Xiangya Hospital of Central South University were reviewed. 260 patients were randomly divided into 2 groups. In the experimental group, there were 138 patients 140 cases of anterolateral thigh flap with one vein one artery anastomosis. In the control group, there were 122 patients 124 cases of anterolateral thigh flap with double vein one artery anastomosis. Results Among 264 anterolateral thigh flaps, the overall success rate of free flap was 98.1% (259/264), 5 free flaps were lost. In the experimental group, there were 6 free flaps occurred venous thrombosis, two of them were lost. In the control group, there were 5 cases occurred venous thrombosis, three of them were lost. No arterial thrombosis occurred in both groups. The time of micromanipulation was 18 to 101 min, with the average of 47 min in the experimental group. In the control group, the time was 45 to 133 min, with the average of 71 min. (P= 0.0003). Conclusion Anterolateral thigh flap with one vein one artery anastomosis for head and neck reconstruction did not affect the survival rate but it can absolutely reduce the operation time. Key words: Anterolateral thigh flap; Micro-vessel anastomosis; Venous thrombosis; Head and neck; Retrospective study

Supraclavicular course of the cephalic vein

Introduction: Vascular access for transvenous pacemaker and cardioverter defibrillator implants is frequently obtained by using the cephalic cutdown technique. Sometimes anatomical variations may limit insertion of one or several leads. We describe a case of a patient with an anomalous supraclavicular course of the left cephalic vein. Case Report: A 61-year-old male with background of ischemic heart disease, hypertension, diabetes mellitus, obstructive sleep apnea and dyslipidemia, was referred to our institution after four months of recurrent syncopal episodes. A bradycardia-tachycardia syndrome was diagnosed and decided to proceed with permanent pacemaker implantation. Through a cutaneous incision in the left deltopectoral groove, we dissected the tissue planes until the left cephalic vein became visible. Fluoroscopy in anterior-posterior projection showed clear supraclavicular course of the cephalic vein. This access was abandoned by removing both wires and ligating the proximal end of the cephalic vein. Through a fluoroscopy/ venogram guided axillary puncture using the modified Seldinger technique and the retained wire technique, double central vein access was secured, allowing the passage of right atrial and ventricular leads. A dual chamber pacemaker was implanted. Conclusion: Although the supraclavicular course of the cephalic vein is a rare anatomical variant, it is important to recognize its presence as it may lead to potential complications related to lead dysfunction, erosion or collateral vascular damage if used as an access for permanent lead placement. Alternative central vein access is strongly recommended in such cases.

Complications and Graft Survival in Kidney Transplants With Vascular Variants: Our Experience and Literature Review

IntroductionIn the literature several reconstructive techniques for vascular anastomoses in case of kidney graft vascular variants are reported. This article reports our experience in kidney transplants with vascular anomalies. Materials and methodsBetween January 1996 and June 2012, 154 cadaveric kidney transplantations were performed at our center. In 35 case, vascular variants were found. Among the arterial variants we observed 27 double arteries, 2 cases with 3 arteries, and 1 case with 4 arteries. All cases of Venous variants were double veins. Based on the type of reconstructive technique used, we divided transplants into group A (n = 22) separate multiple arterial anastomoses; group B (n = 8) anastomosis on the aortic patch; group C (n = 4) single anastomosis in case of 2 arteries with a common ostium at the aortic origin. The venous variants were treated with ligation of the vein of smaller caliber. ResultsKidney preparation to the back table lasted on average 50 minutes with no significant differences between the 3 groups and no significant timing increase compared to renal transplants without vascular anomalies (mean warm ischemia 40 minutes, range 30–60 minutes). The mean cold ischemia time was limited to 16 hours from the removal and the mean warm ischemia was 50 minutes (range 30–70 minutes). There were no differences in timing between group C and single anastomoses, whereas groups A and B showed mean warm ischemia time was slightly increased compared to group C (P < .05). There were no significant differences in terms of delayed upturn of graft function and graft survival between groups A, B, and C and compared to transplants without vascular anomalies. ConclusionsIn our series we observed similar results performing the reimplantation on aortic patch and separate multiple arterial anastomoses. Considering our experience, we believe that vascular variants are not an indication to exclude a graft for transplantation.

Incorrect order of draw could be mitigate the patient safety: a phlebotomy management case report

Procedures involving phlebotomy are critical for obtaining diagnostic blood specimens and represent a well known and recognized problem, probably among the most important issues in laboratory medicine. The aim of this report is to show spurious hyperkalemia and hypocalcemia due to inadequate phlebotomy procedure. The diagnostic blood specimens were collected from a male outpatient 45 years old, with no clinical complaints. The tubes drawing order were as follows: i) clot activator and gel separator (serum vacuum tube), ii) K3EDTA, iii) a needleless blood gas dedicated-syringe with 80 I.U. lithium heparin, directly connected to the vacuum tube holder system. The laboratory testing results from serum vacuum tube and dedicated syringe were 4.8 and 8.5 mmol/L for potassium, 2.36 and 1.48 mmol/L for total calcium, respectively. Moreover 0.15 mmol/L of free calcium was observed in dedicated syringe. A new blood collection was performed without K3EDTA tube. Different results were found for potassium (4.7 and 4.5 mmol/L) and total calcium (2.37 and 2.38 mmol/L) from serum vacuum tube and dedicated syringe, respectively. Also free calcium showed different concentration (1.21 mmol/L) in this new sample when compared with the first blood specimen. Based on this case we do not encourage the laboratory managers training the phlebotomists to insert the dedicated syringes in needle-holder system at the end of all vacuum tubes. To avoid double vein puncture the dedicated syringe for free calcium determination should be inserted immediately after serum tubes before EDTA vacuum tubes.

Application of arterialized venous flap with double vein trunks in replantation of degloved fingers

Objective To report the application and results of venous flap with double vein trunks in replantation of degloved fingers.Methods From March 2007 to June 2009, 6 cases of soft tissue defect in the degloved finger were replanted with venous flap with double vein trunks.The interval between injury and operation was 30 minutes to 8 hours.All fingers were replanted by arterialized free venous flap from the ipsilateral forearm with double vein trunks.The flap was 1.8 cm×1.8 cm to 2.2 cm× 5.8 cm in size.The donor site was directly closed.Results Primary wound healing was observed in all 6 cases postoperatively.All the replanted fingers survived completely.In 5 cases the venous flaps survived uneventfully.In 1 case there was partial superficial necrosis of the flap which healed with conservative management.Postoperative follow-up ranged from 6 to 24 months.The flaps and fingers had good circulation, good texture and color match.According to the criteria for functional assessment of amputated finger issued by the Chinese Hand Surgery Society, the results were graded as excellent in4cases, goodin 1 case, andfairin 1 case.Theoverall excellent rate was 82.5%.Conclusion Replantation of degloved finger with fransfer of venous flap with double vein trunks is capable of repairing pulp soft tissue defect and maximizing the restoration of finger appearance and function. Key words: Surgical flaps; Finger injuries; Replantation; Venous flaps

Kidney Transplantation at Annunziata Hospital of Cosenza: Report of 10 Years Experience

Objective Kidney transplantation represents the gold standard for treatment of patients with end-stage renal disease. Herein we sought to report our 10-year experience with cadaveric kidney transplantations. Patients and Methods From February 1995 to September 2008, we performed 115 kidney transplantations. Patients were followed for an average of 4.9 years (range, 2.2–10.6 years). The cold ischemia time (CIT) averaged 13 ± 3 hours, while the mean warm ischemic time was 25 ± 10 minutes. The ureteral-bladder anastomosis was performed using Bracci catheters in the first series of 72 transplants, and double-J stents in the other 41 cases. The average waiting time was 122 ± 21 months. The immunological regimens were prescribed according to the American Society of Nephrology (K/DOQI) with reference to comorbidity and concomitant risk factors and reported drug toxicity events. We transplanted kidneys with anatomic variations, ie, multiple arteries and double veins, and one double transplant of marginal organs. Results Our overall complication rate was 9.18%. The 10-year patient and graft survival rates were 89% and 84%, respectively. The percentage of biopsy-proven acute rejection episodes was 22.16%, while chronic allograft nephropathy (CAN) accounted for 15.3% at 5 years. The incidence of delayed graft function (DGF) was 14.05%. Finally, we noted 3 cases of cardiovascular death. Conclusion Our experience showed excellent patient outcomes compared with other Italian and European data.

Comparison of single and double vein approaches for His bundle ablation and pacemaker placement for symptomatic rapid atrial fibrillation

His Bundle ablation (HBA) with permanent pacemaker (PPM) implantation is an effective strategy for controlling heart rate in symptomatic patients with rapid atrial fibrillation (AF), resistant to pharmacologic therapy. The standard double vein (DV) approach involves mapping and HBA from a femoral approach to achieve complete heart block (CHB), while single chamber (SC), dual chamber (DC), or biventricular (BiV) PPM is then placed via a subclavian approach. We compared 7 patients with drug-resistant rapid AF who underwent the standard DV approach to 8 patients who underwent a single vein (SV) approach, in which HBA and PPM implantation were performed through the subclavian vein. The two groups were compared for acute success in creating CHB, total procedure and fluoroscopy times and patient discomfort. Results are expressed as mean +/- standard error (SEM). The procedure times for the SV versus DV were 70.4 +/- 11.4 v 100.0 +/- 19.2 min, and the fluoroscopy times, 13.9 +/- 3.1 (SV) v 13.0 +/- 2.9 (DV). All patients were discharged in stable condition with CHB and SC, DC pacemaker or BiV/Implantable Cardioverter Defibrillator (ICD). CHB with symptomatic improvement was maintained in all patients over a mean follow-up period of 22.6 months (SV), and 9.6 months (DV). The SV approach for HBA combined with PPM implantation was at least as effective and may be more efficient than the classic DV approach, and should be considered as an alternative to DV technique to reduce procedural time and patient discomfort.