Inflow Vessels Research Articles

Midterm Outcomes and Predictors of Failure of Lower Extremity Bypass to Para-Malleolar and Pedal Targets

ObjectivesThe frequency of distal lower extremity bypass (LEB) for infra-popliteal critical limb threatening ischemia (IP-CLTI) has significantly decreased. Our goal was to analyze the contemporary outcomes and factors associated with failure of LEB to para-malleolar and pedal targets. MethodsWe queried the VQI infra-inguinal database from 2003-2021 to identify LEB to para-malleolar or pedal/plantar targets. Primary outcomes were graft patency, major adverse limb events [vascular re-intervention, above ankle amputation] (MALE), and amputation-free survival at 2 years. Standard statistical methods were utilized. ResultsWe identified 2331 LEB procedures (1265 anterior tibial at ankle/dorsalis pedis, 783 posterior tibial at ankle, 283 tarsal/plantar). The prevalence of LEB bypasses to distal targets has significantly decreased from 13.37% of all LEB procedures in 2003 to 3.51% in 2021 (p<0.001). The majority of cases presented with tissue loss (81.25. Common post-operative complications included major adverse cardiac events (8.9%) and surgical site infections (3.6%). Major amputations occurred in 16.8% of patients at 1 year. Post-operative mortality at 1 year was 10%.On unadjusted Kaplan-Meier survival analysis at 2 years, primary patency was 50.56%±3.6%, MALE was 63.49%±3.27%, and amputation-free survival was 71.71%±0.98%. In adjusted analyses [adjusted for comorbidities, indication, conduit type, urgency, prior vascular interventions, graft inflow vessel (femoral/popliteal), concomitant inflow procedures, surgeon and center volume] conduits other than GSV (p<0.001) were associated with loss of primary patency and increased MALE. High center volume (>5 procedures/year) was associated with improved primary patency (p=0.015), and lower MALE (p=0.021) at 2 years. ConclusionsDespite decreased utilization, open surgical bypass to distal targets at the ankle remains a viable option for treatment of IP-CLTI with acceptable patency and amputation-free survival rates at 2 years. Bypasses to distal targets should be performed at high volume centers to optimize graft patency and limb salvage and minimize re-interventions.

A vertebrobasilar junction aneurysm successfully treated with a combination of surgical clipping and flow diverter placement based on the results of computational fluid dynamics analysis: illustrative case.

The treatment of vertebrobasilar junction (VBJ) aneurysms is challenging. Although flow diverters (FDs) are a possible treatment option, geometrical conditions hinder intervention. VBJ aneurysms possess dual inflow vessels from the bilateral vertebral arteries (VAs), one of which is ideally occluded prior to FD treatment. However, it remains unclear which VA should be occluded. A 75-year-old male with a growing VBJ complex aneurysm exhibiting invagination toward the brainstem and causing perifocal edema required intervention. Preoperative computational fluid dynamics (CFD) analysis demonstrated that left VA occlusion would result in more stagnant flow and less impingement of flow than right VA occlusion. According to the simulated strategy, surgical clipping of the left VA just proximal to the aneurysm was performed, followed by FD placement from the basilar artery trunk to the right VA. The patient demonstrated tolerance of the VA occlusion, and follow-up computed tomography angiography at 18 months after FD treatment confirmed the disappearance of the aneurysm. Preoperative flow dynamics simulations using CFD analysis can reveal an optimal treatment strategy involving a hybrid surgery that combines FD placement and direct surgical occlusion for a VBJ complex aneurysm.

Thrombectomy of the Profunda Femoral Vein in Iliofemoral Deep Venous Thrombosis Using an Antegrade Popliteal Approach.

Residual or undertreated inflow disease is a major cause of stent occlusion following endovascular thrombectomy for iliofemoral deep venous thrombosis (DVT). The profunda femoral vein (PFV) is an important inflow vessel alongside the femoral vein but is traditionally challenging to treat via an antegrade popliteal approach. This technical note describes a novel approach for PFV clearance in iliofemoral thrombectomy via the popliteal vein. Eight patients underwent PFV clearance as part of iliofemoral DVT thrombectomy via an antegrade popliteal approach. In seven patients, a popliteal-profunda communicating vessel was identified permitting PFV access and thrombectomy. In one patient, a popliteal-profunda communicator was not identified and an 'up and over' approach via the femoral bifurcation from the same popliteal access was utilised. Thrombectomy was performed using the Inari ClotTriever device or Penumbra's Indigo system. Technical success in PFV thrombectomy was 100%. Six patients (75%) underwent stenting for an iliac stenotic lesion or May Thurner compression point. At the four-week ultrasound follow-up, the pelvic iliofemoral segment was patent in 7 patients (87.5%). The PFV was patent in 7 patients (87.5%) whereas the FV was only patent in 4 patients (50%). One patient underwent reintervention for iliofemoral stent occlusion. No PFV injury occurred and no post-procedure profunda reflux was identified. PFV clearance can be achieved via an antegrade popliteal approach in iliofemoral thrombectomy to optimise inflow, negating the need for alternative or additional venous access. PFV may maintain upstream iliofemoral vein patency even with an occluded femoral vein. Level 4, Case Series.

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

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

A New Perspective on an Old Problem: The Inferior Epigastric Artery as Inflow Target for Accessory Polar Vessels in Renal Transplantation

The use of kidney allografts with multiple renal arteries (MRAs) in kidney transplantation is no longer considered a contraindication to renal transplantation. Traditional decision on best management of accessory renal vessels has been guided by surgeons' surgical experience and institutional experience. The role of inferior epigastric artery (IEA) as an inflow vessel has often been relegated as a secondary option for allografts with MRAs due to perception of greater technical challenge and worse outcomes.

The "pipe-anchor" technique: A method for intra-aneurysmal loop reduction using a partially unsheathed pipeline stent.

Large aneurysms often present a challenge for endovascular navigation, as they may require utilization of "around-the-world" technique for distal access. In this study, we describe the use of a pipeline stent to stabilize the microcatheter allowing gradual unsheathing and straightening of the microcatheter within the aneurysm enabling stent deployment. A pipeline stent is partially deployed distal to the aneurysm, after using intra-aneurysmal loop ("around-the-world") to cross the aneurysm. Partially unsheathed, using its radial force and vessel wall friction to establish an anchoring point, the microcatheter is stabilized and pulled with the stent locked to gradually to allow loop reduction and microsystem straightening, allowing unsheathing as the microsystem is aligned with the inflow and outflow vessel. Two patients harboring cavernous segment aneurysms (measuring 18 × 12 mm and 21 × 24 mm) were treated by 3.75 × 25 mm and 4.25 × 25 mm pipeline devices, respectively, using this technique, deployed through a Phenom 0.027" microcatheter. Patients did well clinically with no thromboembolic complications, as follow-up imaging demonstrated good wall apposition and appreciable contrast stagnation. Anchoring for loop reduction was previously described using a non-flow diverter stents or balloon requiring additional devices and exchange maneuvers to deploy a pipeline. The "pipe anchor" technique describes the use of a partially deployed flow diverter system as an anchor. This report suggests that pipeline radial force, albeit low, is sufficient. We believe that this method is worthy of consideration in select cases as a first choice and can be valuable tool in the armamentarium of the endovascular neurosurgeon.

A Case Report of Successful Renal Transplantation After Surgically Treated Type A Aortic Dissection

BackgroundAortoiliac lesions can influence the results of kidney transplantation and increase technical difficulties during surgery. Aortic dissection (AD) is a rare and infrequently reported event before transplantation, whereas immediate optimal perfusion is paramount for kidney transplantation. Thus, adequate blood flow imposed by the flow from the true lumen must be considered when choosing a target inflow vessel. Case presentationA 67-year-old man on dialysis with end-stage renal disease caused by immunoglobulin A nephropathy was referred for kidney transplantation. He had successfully undergone conventional Stanford type A AD surgery 3 years ago. Pretransplant contrast-enhanced computed tomography angiography revealed termination of the distal intimal flaps within the common iliac arteries. Dilation of the descending aorta was also observed. Based on the meticulous vascular assessment, including consultation with the cardiovascular surgery department, the right internal iliac artery (IIA) was considered usable for anastomosis. He underwent living unrelated kidney transplantation from his 66-year-old wife. The patency and blood flow in the right IIA were also verified using intraoperative findings. Without any special procedure, we used a side-to-end arterial anastomosis between the donor renal artery and recipient IIA. After vascular clamp removal, the allograft was perfused homogeneously and immediately functioned. ConclusionPatients receiving previous surgery for type A AD can successfully undergo kidney transplantation if the patency of the iliac arteries from the true lumen is confirmed by perioperative evaluation, and the artery can be carefully clamped to avoid possible further dissection.

New Hybrid Procedure Shows Improved Patency of Iliofemoral Stenting in Patents With Compromised Infrainguinal Inflow Vessels in Post-Thrombotic Chronic Venous

New Hybrid Procedure Shows Improved Patency of Iliofemoral Stenting in Patents With Compromised Infrainguinal Inflow Vessels in Post-Thrombotic Chronic Venous

Staged autogenous to prosthetic hemodialysis access creation strategy to maximize forearm options

ObjectiveWhen an adequate cephalic vein is not available for fistula construction, surgeons often turn to basilic vein or prosthetic constructions. Single-stage forearm prosthetic hemodialysis accesses are associated with poor durability, and upper arm non-autogenous access options are often limited by axillary outflow failure, which inevitably drives transition to the contralateral arm or lower extremity. We hypothesized that initial creation of a modest flow proximal forearm arterial-venous anastomosis to dilate (“develop”) inflow and outflow vessels, followed by a planned second-stage procedure to create a cannulation zone with a prosthetic graft in the forearm, would result in reliable and durable hemodialysis access in patients with limited options. MethodsWe performed an institutional cohort study from 2017 to 2021 using a prospectively maintained database supplemented with adjudicated chart review. Patients without traditional autogenous hemodialysis access options in the forearm underwent an initial non-wrist arterial-venous anastomosis creation in the forearm as a first stage, followed by a second-stage interposition graft sewn to the existing inflow and venous outflow segments to create a useable cannulation zone in the forearm while leveraging vascular development. Outcomes included time from second-stage access creation to loss of primary and secondary patency, frequency of subsequent interventions, and perioperative complications. ResultsThe cohort included 23 patients; first-stage radial artery-based (74%) configurations were more common than brachial artery-based (26%). Mean age was 63 years (standard deviation, 14 years), and 65% were female. Median follow-up was 340 days (interquartile range [IQR], 169-701 days). Median time to cannulation from second-stage procedure was 28 days (IQR, 18-53 days). Primary, primary assisted, and secondary patency at 1 year was 16.7% (95% confidence interval [CI], 5.3%-45.8%), 34.6% (95% CI, 15.2%-66.2%), and 95.7% (95% CI, 81.3%-99.7%), respectively. Subsequent interventions occurred at a rate of 3.02 (IQR, 1.0-4.97) per person-year, with endovascular thrombectomy with or without angioplasty/stenting (70.9%) being the most common. There were no cases of steal syndrome. Infection occurred in two cases and were managed with antibiotics alone. ConclusionsFor patients without adequate distal autogenous access options, staged prosthetic graft placement in the forearm offers few short-term complications and excellent durability with active surveillance while strategically preserving the upper arm for future constructions.

Hyperrealistic Rendering of Type II Endoleak.

HomeRadiologyRecently Published PreviousNext Reviews and CommentaryFree AccessImages in RadiologyHyperrealistic Rendering of Type II EndoleakBaolei Guo , Liying PengBaolei Guo , Liying PengAuthor AffiliationsFrom the Department of Vascular Surgery, Zhongshan Hospital, Fudan University, No. 180 Fenglin Rd, Xuhui District, Shanghai 200032, China (B.G.); and Central Research Institute, United Imaging Healthcare, Shanghai, China (L.P.).Address correspondence to B.G. (email: [email protected]).Baolei Guo Liying PengPublished Online:Feb 14 2023https://doi.org/10.1148/radiol.222150MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Supplemental material is available for this article.A 71-year-old man with a history of abdominal aortic aneurysm status after endovascular aortic repair (EVAR) presented for follow-up CT angiography (CTA) at 19 months. Hyperrealistic rendering (HRR) (United Imaging Healthcare) visually demonstrated an enlarged aneurysm sac measuring 7.2 cm in maximum diameter (previously 6.1 cm, before EVAR), with type II endoleaks involving the bilateral L4 lumbar arteries and the inferior mesenteric artery (Figure, Figure S1, Movie). The patient was admitted to the hospital and underwent embolization of the aforementioned feeding vessels. Follow-up CTA at 6 months after the embolization procedure showed complete thrombosis of the aneurysm sac with no residual endoleak.Images in a 71-year-old man diagnosed with type II endoleak 19 months after the endovascular aortic repair for an abdominal aortic aneurysm. The hyperrealistic rendering from CT angiography provides a clear representation of the endoleak (black arrows) and the three major feeding vessels (white arrows) (ie, bilateral lumbar arteries [LA] and the inferior mesenteric artery [IMA]). (A) The hyperrealistic rendering in posterior view demonstrates the feeding lumbar arteries and the associated iliolumbar-lumbar pathway arising from the internal iliac arteries. (B) The hyperrealistic rendering in anterior view reveals a pathway from the superior mesenteric artery to the inferior mesenteric artery by means of the arc of Riolan feeding into the aneurysm sac (shown as a semitransparent cavity).Download as PowerPointOpen in Image Viewer Get the Flash Player to see this video.Movie: Hyper-realistic rendering from CT angiography in a 71-year-old man diagnosed with type II endoleak.Download Original Video (97.3 MB)Endoleaks, in particular type II endoleaks defined as aneurysm sac backfilling from aortic branches (1), are the most common complications of EVAR and pose persistent risk of aortic rupture. Visualization of the inflow vessels is crucial for preoperative planning. As an advanced three-dimensional visualization technique with use of physically based volume rendering, HRR can generate photorealistic images with enhanced display of complex spatial relationships and lifelike surface details. By assisting proceduralists in identifying the endoleak feeding vessels, HRR provides value in developing treatment strategies.Disclosures of conflicts of interest: B.G. No relevant relationships. L.P. No relevant relationships.Supported by the National Natural Science Foundation of China (grant 82000436) and the Science and Technology Commission of Shanghai Municipality (grants 201409004800 and 21410710500).Reference1. Veith FJ, Baum RA, Ohki T, et al. Nature and significance of endoleaks and endotension: summary of opinions expressed at an international conference. J Vasc Surg 2002;35(5):1029–1035. Crossref, Medline, Google ScholarArticle HistoryReceived: Aug 29 2022Revision requested: Oct 10 2022Revision received: Oct 21 2022Accepted: Oct 31 2022Published online: Feb 14 2023 FiguresReferencesRelatedDetailsRecommended Articles RSNA Education Exhibits RSNA Case Collection Recently Published Supplemental MaterialMetrics Altmetric Score PDF download

조선 초기 물시계의 제작과 운용에 대한 재검토

This paper reviews the use of water clocks in the early Joseon Dynasty from the era of King Taejo till the days of King Seongjong. More specifically, it traces the creation of Jagyeongnu (自擊漏, automatically-striking clepsydra) the organization and maintenance of Geumru (禁漏) of Seoun-gwan (書雲觀, Bureau of Astronomy), and the repair and improvement of Jagyeongnu in the post King Sejong era. From the early days, Joseon Dynasty strove to utilize water clocks as its national standard clock. Jagyeongnu, completed under King Sejong’s reign, was the product of efforts to create the most advanced water clock that solves problems with previous water clocks. King Sejong and his officials studied works on Chinese historical clepsydras to fix the problems of the past water clocks and used the knowledge gained in designing Jagyeongnu in 1433. After a year of test operation, Jagyeongnu became the national standard clock on July 1st, 1434. The main staffs in charge of the operation of national water clocks, including Jagyeongnu, were officials called ‘Geumru’, members of Seoun-gwan. In the process of the reform of government organization, Geumru was affiliated as junior officials under Seoun-gwan, started with the 40 members and reorganized as 30 peoples in November 1475, and this number was written in Gyeongguk-Daejeon (經國大典), the National Code of Joseon Dynasty. The operation of an automatic clepsydra such as Jagyeongnu incurred many difficulties. As witnessed in several cases since the era of King Munjong, malfunction could be bred in the compartments of automatic water clocks: the water supply system comprised of water-supply vessels and inflow vessels, power transmission devise using iron balls, and the time casting apparatus. This was why there were continuous suggestions for repairs of water clocks since the full-scale operation of Jagyeongnu.

Contemporary utilization of the axillary artery in cardiac surgery.

The axillary artery is a reliable inflow vessel when addressing pathology of the aortic root and aortic arch that may preclude standard central cannulation strategies. This narrative review examines the use of the axillary artery in cardiac surgery. Anatomy, indications for use, cannulation strategies, and potential complications will be discussed. A comprehensive review of the current literature was performed using PubMed, Cochrane Review, and authoritative committee guidelines. A narrative review incorporating current available evidence was undertaken. Use of the axillary artery in select cardiac surgical cases is reliable, reproducible, and may be preferable in certain cases involving ascending aortic pathology, reoperative surgery, porcelain aorta, access for transcatheter valve therapies, and peripheral mechanical circulatory support.

Performance of Open and Closed Cell Laser Cut Nitinol Stents for the Treatment of Chronic Iliofemoral Venous Outflow Obstruction in Patients Treated at a Single Centre

A number of dedicated self expanding nitinol stents have been developed for use in the venous system, with both open cell (OC) and closed cell (CC) designs available. Data comparing these different designs are lacking. The objective of this study was to evaluate outcomes in patients treated with open and closed cells for unilateral chronic iliac vein obstruction. A single centre retrospective cohort study was conducted, including all patients treated with a dedicated nitinol venous stent between 2014 and 2019. Stent patency and details of re-interventions (including lysis, venoplasty, reinforcement, extension, arteriovenous fistula formation) were examined in the first post-operative year. Subgroup analysis described outcomes for patients treated with OC and CC stents ending above the inguinal ligament and those who required extension into the common femoral vein. Cox regression analysis was used to identify factors associated with loss of primary patency. A total of 207 patients were included (OC 100 patients, CC 107 patients). There was no significant difference between the groups for age (OC 42 years, CC 44 years); gender (OC and CC 67% female); presence of post-thrombotic lesions (OC 71%, CC 73%); stenting across the inguinal ligament (OC 58%, CC 56%), or presence of inflow disease (OC 49%, CC 47%). Primary and cumulative patency at 12 months were similar between groups (primary: OC 63%, CC 65%; cumulative: OC 93%, CC 90%). Patients with a CC stent across the inguinal ligament had a greater risk of needing multiple re-interventions at one year compared with those with an OC stent (odds ratio 2.84, 95% confidence interval [CI] 1.16 – 6.9) but overall, the only factor significantly associated with loss of primary patency was inflow vessel disease (hazard ratio 3.39, 95% CI 1.73 – 6.62, p < .001). OC and CC dedicated nitinol venous stents were observed to perform similarly in terms of patency and symptom improvement at one year. Disease of the inflow vessels was the most important factor associated with a loss of stent patency irrespective of stent design.

P121. THE USE OF FLOW-THROUGH FREE FLAPS FOR HEAD AND NECK RECONSTRUCTION

PURPOSE: Reconstructive obstacles in composite head and neck defects are compounded in re-operated, irradiated, and vessel-depleted surgical fields. In cases that require multiple free flaps, recipient vessel availability and inset logistics become challenging. Strategic flow-through flap configurations mitigate these issues by providing a built-in option for inflow to a second flap. This approach permits use of one native recipient vessel, increased reach of the inflow vessels, and greater flexibility to configure soft tissue and bony flap inset. METHODS: 38 head and neck free flap cases were reviewed from an academic hospital in New Orleans, Louisiana, taking place between March 2019 - April 2021. Nine cases utilized flow-through free flaps for reconstruction. RESULTS: Seven oncologic and two traumatic patients (N=9) received multiple flaps arranged in flow-through configuration (ALT: 78%; Fibula: 78%; DCIA: 22%; Peroneal Artery Perforator: 11%; MSAP: 11%) for reconstruction. Configurations involved ALT -> Fibula (56%), ALT -> DCIA (22%), Fibula -> Peroneal artery perforator (11%), Fibula -> MSAP (11%). Recipient vessels included facial (78%), transverse cervical (11%), and occipital (11%) arteries. No flap failures occurred, though complications included infection (22%), dehiscence (44%), hematoma (22%), thrombosis (11%), and others (33%). CONCLUSIONS: In head and neck reconstruction, the use of the flow-through principle enables uninterrupted vascular flow for two distinct free flaps in single stage reconstruction for patients with vessel-depleted, irradiated, and re-operated fields.

Dynamic, Time-Resolved CT Angiography After EVAR: A Quantitative Approach to Accurately Characterize Aortic Endoleak Type and Identify Inflow Vessels

Purpose: Our purpose was to study the accuracy of dynamic computed tomography angiography (d-CTA) in characterizing endoleak type, inflow vessels as compared with digital subtraction angiography (DSA) using qualitative and quantitative analysis. Methods: Between March 2019 and January 2021, all patients who underwent d-CTA imaging after EVAR were retrospectively reviewed. Two blinded independent reviewers qualitatively reviewed d-CTA and DSA images. Quantitative region of interest (ROI) analysis was performed by measuring time-resolved contrast enhancement within the aorta and endoleak lesion(s) in the aneurysm sac. Differences between time-to-peak enhancement (Δ TTP) across different ROIs were quantified. Results: A total of 48 patients underwent d-CTA during the study period, of whom 24 patients had abdominal EVAR and DSA imaging for comparison. Qualitative review of DSA imaging showed type I (n=4), type II (n=16), and type III (n=2) and no endoleak (n=2). In 23 of 24 patients (95.8%), d-CTA findings correlated with DSA findings for endoleak type. One patient had a type III endoleak that was demonstrated only in d-CTA (arising from defect in polymer sealing ring of Ovation stent graft) imaging. In type II endoleak cases, d-CTA identified more inflow vessels than DSA imaging (33 vs 21 vessels, p=0.010). Quantitative analysis showed mean (±SD) Δ TTP values for type I endoleak as 1.8 (±1.8) seconds, type II as 9.6 (±3.5) seconds, and for type III endoleak as 5.6 (±1.3) seconds. Conclusion: Dynamic CTA can accurately characterize aortic endoleak type, inflow vessels as compared with DSA imaging. Quantitative parameters such as Δ TTP enhancement can help better differentiate endoleak types and provide an objective approach to endoleak diagnosis.

Performance of Open and Closed Cell Laser Cut Nitinol Stents for the Treatment of Chronic Iliofemoral Venous Outflow Obstruction in Patients Treated at a Single Centre

A number of dedicated self expanding nitinol stents have been developed for use in the venous system, with both open cell (OC) and closed cell (CC) designs available. Data comparing these different designs are lacking. The objective of this study was to evaluate outcomes in patients treated with open and closed cells for unilateral chronic iliac vein obstruction. A single centre retrospective cohort study was conducted, including all patients treated with a dedicated nitinol venous stent between 2014 and 2019. Stent patency and details of re-interventions (including lysis, venoplasty, reinforcement, extension, arteriovenous fistula formation) were examined in the first post-operative year. Subgroup analysis described outcomes for patients treated with OC and CC stents ending above the inguinal ligament and those who required extension into the common femoral vein. Cox regression analysis was used to identify factors associated with loss of primary patency. A total of 207 patients were included (OC 100 patients, CC 107 patients). There was no significant difference between the groups for age (OC 42 years, CC 44 years); gender (OC and CC 67% female); presence of post-thrombotic lesions (OC 71%, CC 73%); stenting across the inguinal ligament (OC 58%, CC 56%), or presence of inflow disease (OC 49%, CC 47%). Primary and cumulative patency at 12 months were similar between groups (primary: OC 63%, CC 65%; cumulative: OC 93%, CC 90%). Patients with a CC stent across the inguinal ligament had a greater risk of needing multiple re-interventions at one year compared with those with an OC stent (odds ratio 2.84, 95% confidence interval [CI] 1.16 - 6.9) but overall, the only factor significantly associated with loss of primary patency was inflow vessel disease (hazard ratio 3.39, 95% CI 1.73 - 6.62, p < .001). OC and CC dedicated nitinol venous stents were observed to perform similarly in terms of patency and symptom improvement at one year. Disease of the inflow vessels was the most important factor associated with a loss of stent patency irrespective of stent design.

A case report of duodenal arteriovenous malformation: usefulness of intraoperative indocyanine green angiography for precise identification of the lesion

BackgroundArteriovenous malformation (AVM) of the gastrointestinal (GI) tract can cause bleeding. The treatment choice for GI tract AVM is surgical resection of the involved bowel segment with complete resection of the nidus. The AVM formed in the duodenum or pancreatic head could also cause gastrointestinal bleeding, and there are several reports of pancreaticoduodenectomy as its treatment. However, if the area of AVM can be accurately identified during surgery, it may be possible to completely resect the AVM while preserving the organ. We report a case of duodenal AVM in a patient successfully treated with a subtotal stomach-preserving duodenal bulb resection using intraoperative indocyanine green (ICG) angiography technique.Case presentationAn 18-year-old man was diagnosed with duodenal AVM after several examinations for anemia and was referred to our hospital for further treatment. Preoperative imaging studies showed that the inflow vessels of this duodenal AVM were the inferior pyloric artery and the superior duodenal artery, and the AVM was localized to the duodenal bulb. Thereafter, stomach-preserving duodenal bulb resection preceded by ligation of the inflow vessels was performed. During the surgery, ICG angiography clearly demonstrated the area, where the nidus was distributed, and a duodenal bulb resection with complete resection of the AVM was successfully performed. There was no recurrence at the 6-month follow-up.ConclusionsIntraoperative ICG angiography was a useful procedure for precise identification of the AVM of the GI tract.

Analysis of Hemodynamic Changes After Medial Patellofemoral Ligament Reconstruction.

The resumption of blood flow is an important factor in the remodeling process of the graft. The purpose of this study is to evaluate hemodynamic changes after medial patellofemoral ligament (MPFL) reconstruction using magnetic resonance angiography (MRA) as the evaluation of graft remodeling. Eleven knees that underwent anatomical MPFL reconstruction with the semitendinosus tendon were studied. We evaluated the blood flow around the bone tunnel wall in the arterial phase using MRA approximate 3 months and 1 year after surgery. Clinical and radiological evaluations were also analyzed. MRA showed an inflow vessel into the bone tunnel wall from the medial superior genicular artery on the femoral side, and from the articular branch of the descending genicular artery and the medial superior genicular artery on the patellar side. This contrast effect was decreased at 12 months after surgery in all cases. The clinical scores improved from baseline one year postoperatively. We revealed the blood flow to the bone tunnel wall after anatomical MPFL reconstruction is detected by MRA. The blood flow started within 2 or 3 months postoperatively and was sustained for 12 months. This study supported remodeling of the graft continues 3 months after surgery when the conformity of the patellofemoral joint stabilizes.

Successful ligation of posterior tibial vein aneurysm performed according to intraoperative venography results.

A 23-year-old woman was diagnosed with a posterior tibial vein aneurysm that had resulted in deep vein thrombosis and a pulmonary embolism. The patient responded well to anticoagulation therapy, and surgical resection was planned to prevent recurrence. She was scheduled to undergo tangential aneurysmectomy and lateral venorrhaphy. However, the aneurysm could not be completely exposed because of adhesions. Therefore, venography was performed to identify the inflow and outflow vessels, which were ligated because an accessory venous communication was identified. Intraoperative venography can aid in the selection of simple ligation or reconstruction of a venous communication for the treatment of posterior tibial vein aneurysms.

Medium-term outcomes after inferior vena cava reconstruction for acute and chronic deep vein thrombosis and retroperitoneal fibrosis

ObjectiveIn the present study, we evaluated the technical and clinical outcomes after endovascular inferior vena cava (IVC) reconstruction in patients with nonmalignant obstruction. MethodsThe preoperative, procedural, and follow-up medical records and imaging studies were retrospectively reviewed for 59 consecutive patients who had undergone endovascular IVC reconstruction for nonmalignant obstruction from February 2014 to January 2019. The patients were classified into three groups according to the quality of their infrainguinal inflow vessels. The outcomes measured were the primary, primary-assisted, and secondary patency rates, reintervention rates, and symptomatic resolution. ResultsThe indications for treatment were post-thrombotic syndrome (n = 41), acute deep vein thrombosis (n = 12), and retroperitoneal fibrosis (n = 6). The median patient age was 37 years, 11 months, 71.2% were men, and 32.2% had a diagnosis of thrombophilia, with no significant difference in these demographics between the three inflow groups. The median follow-up duration was 2 years, 3 months (range, 6 months to 6 years, 5 months). The whole-cohort primary patency was 91.2%, 71.0%, and 24.1% at 1, 3, and 5 years, respectively. Secondary patency was 76.7% at 1 year and 66.4% at both 3 and 5 years. Inflow group A (no post-thrombotic disease in the femoral or deep femoral veins) demonstrated significantly higher primary patency compared with group B (stenotic disease in one or two infrainguinal inflow veins; P = .009) and significantly higher secondary patency than for both groups B (P = .008) and C (all three infrainguinal inflow veins had stenosed or femoral and/or deep femoral vein occlusion was present; P = .04). In post-thrombotic syndrome patients, the Villalta scores had decreased from a mean of 14.2 to 8.1 at 1 year and 6.8 at 2 years, and the Venous Insufficiency Epidemiological and Economic Study Quality of Life score had improved from a mean of 19.8 to 54.1 and 57.3 at 1 and 2 years, respectively. In the patients with acute deep vein thrombosis, the Villalta score was 2.8 at 1 year and 0 at 2 years. In the patients with retroperitoneal fibrosis, the Venous Insufficiency Epidemiological and Economic Study Quality of Life score had improved from a mean of 25.3 at baseline to 44 at 6 months. ConclusionsEndovascular IVC reconstruction for nonmalignant obstruction can achieve good patency and clinical improvement, although the outcomes were poorer for patients with post-thrombotic disease of the femoral and deep femoral veins.