Vein Interposition Graft Research Articles

Digital artery reconstruction with interposition vein graft: impact on secondary Raynaud's phenomenon.

Patients with secondary RP show a wide range of symptoms depending on the condition of vascular structures. If the symptoms are localized to specific fingers and angiography reveals a discrete segment of occlusion of a proper digital artery, we perform proper digital artery reconstruction with an interposition vein graft. The objective of this study was to evaluate the results of the surgery in patients with chronic hand ischaemia. A retrospective chart review was performed on patients who underwent proper digital artery reconstruction. Each digit that underwent grafting was analysed separately. The results of surgical intervention and recurrence based on patient symptoms were evaluated. Cox proportional hazards regression models were used to identify independent risk factors associated with recurrence, and the Kaplan-Meier method was used to predict the 5-year recurrence-free rate. A total of 79 digits from 57 patients were included in this study. The majority of patients demonstrated resolution of ischaemic pain and ulceration (97.5% and 95.3%, respectively). Recurrence occurred in 16 (20.3%) patients during the follow-up period. In two cases (2.5%) surgery had no effect. In the multivariate Cox regression analysis, smoking and concomitant periarterial sympathectomy were significant factors associated with recurrence. In the Kaplan-Meier analysis, the 5-year recurrence-free rate in the total study population was 69.3%. Digital artery reconstruction using an interposition vein graft is an effective procedure for improving ischaemic pain and ulceration in patients with RP. Smoking and concomitant periarterial sympathectomy were significantly associated with recurrence.

Use of Proximal Suboccipital Segment of Occipital Artery as Donor for Posterior Circulation Revascularization Surgery: Technical Note

The distal suboccipital segment of the occipital artery is commonly used as a donor vessel for aneurysms of the posterior circulation requiring revascularization techniques. Isolating this segment of vessel can be challenging due to its course in and out of the various layers of the suboccipital musculature. We describe the use of the proximal suboccipital segment of the occipital artery within the occipital groove at the lateral skull base as a donor segment for an interposition graft in revascularization surgery. We present a case detailing the use of this technique for treatment of a dissecting PICA aneurysm and photographs from cadaveric dissections demonstrating relevant anatomy. Our patient is a 62-year-old man who presented with a high-grade subarachnoid hemorrhage from a proximal dissecting-type aneurysm of the posterior inferior cerebellar artery (PICA). Endovascular options were limited to coil sacrifice of the parent vessel, and thus the patient was taken for a far lateral craniotomy, trapping of the aneurysm, and revascularization of the PICA territory via a saphenous vein interposition graft sewn proximally and distally to the occipital artery within the occipital groove and a cortical segment of the affected PICA, respectively. Postoperative imaging demonstrated filling of the PICA territory via the graft, and the patient ultimately recovered from his subarachnoid hemorrhage. The use of the proximal suboccipital segment of the occipital artery is a viable option for a donor in posterior fossa revascularization surgery.

1168 Case Report: Lower Limb Trauma with Vascular and Orthopaedic Injury in a National Level Gymnast

Abstract Traumatic injuries in high-functioning athletes can have devastating consequences and require cross-disciplinary management for both initial presentation and subsequent management. We would like to present the case of a 17-year-old female, national level gymnast who presented with a traumatic lower limb injury. During a run-up to a trampoline, her right knee gave way with immediate pain, deformity, and inability to weight-bear. At initial assessment she was noted to have a large joint effusion with inability to straight leg raise and Xray showed a tibial plateau avulsion fracture. Initially she was neuro-vascularly intact, however on splinting, posterior knee dislocation occurred with loss of foot pulses, sensation, and motor function of the lower leg. Computerised tomography angiogram showed an 8cm filling defect at the popliteal artery. A multidisciplinary approach between Vascular and Orthopaedics decided on initial surgical management with support from Paediatrics and Anaesthesia. The popliteal artery was approached posteriorly for long-term durability and function, despite the potential difficulty in exposure, with a medial approach bailout. Exposure of the popliteal artery revealed a section of torn intima with occlusion which was resected and replaced with a long saphenous vein interposition graft. Finally, four-quadrant fasciotomies and spanning external fixation of her knee was performed. Completion diagnostic angiogram confirmed graft patency and restored 2-vessel run off. The patient recovered from this limb-salvage procedure and although required several more orthopaedic procedures, she was eventually discharged mobilising with crutches. This case illustrates the importance of a multidisciplinary approach in managing complex trauma especially in high-performing individuals.

Improving the Early Outcome of Digital Replantation: Technical Tricks Learned in a US Fellowship

Abstract Background Despite stable numbers of upper limb amputations there is a decline in replantation in Europe. This results in lacking experience, decreasing success rates, and fewer attempts. Training in high-volume centers is crucial for hand surgeons performing upper extremity replantation. Aims This abstract highlights the experience in a US microsurgery fellowship. Methods Upper extremity revascularization and replantation cases during a 10 month - period were retrospectively reviewed. Overall, the fellow was exposed to 29 cases: 2 hand, 5 thumb and 9 digitial replantations as well as 13 thumb and digital revascularizations. Primary outcome was the survival of the injured body part. Secondary outcomes were total case time, number of repaired arteries/veins, the use of vein grafts, and early free flap coverage. Whenever possible, all microsurgical steps including vessel debridement and anastomosis were performed under tourniquet. Results Success rate was 21/29 (72%). Failure was limited to avulsion or crush injuries. Mean surgery time for revascularization was 92 min (range, 45-134 min) per digit. Mean surgery time for thumb and single digit replantation was 133 min (range, 62-270 min) and for the two hand replantations 180 min and 300 min, respectively. Routinely, only 1 dominant artery was repaired. Forearm or saphenous vein grafts were used in 14/29 cases. Only in 3/23 cases > 1 vein was repaired and in 3 cases interpositional vein grafts were used for dorsal vein reconstruction. One venous flow-through flap was used and a dorsal hand soft tissue defect was covered with a fascio-cutaneous free flap 5 days after replantation. Conclusions Replantation remains a challenge for hand surgeons. The thoughtful use of a tourniquet with vessel debridement in a bloodless field is key to maximize the efficiency of replantation. Furthermore, the liberate use of vein grafts and venous flow-through flaps helps moving outside the trauma zone, thus increasing the likelihood of upper limb salvage.

A retrospective study on the outcomes of stapedotomy with vein graft interposition and vein graft surround techniques.

This study evaluated audiological outcomes of stapedotomy using two different techniques, vein graft interposition and vein graft surround, for sealing the stapes fenestra. A retrospective study of 130 patients who underwent stapedotomy for otosclerosis was performed. A total of 84 patients underwent the vein graft surround procedure and 46 underwent the vein graft interposition procedure. Post-operative hearing outcome was compared between them. A total of 55 of 130 patients had a post-operative air-bone gap of less than 10 dB. A total of 57 patients had an air-bone gap within 20 dB. The average air-bone gap was 13.16 dB at 3 months with a mean improvement of 22.06 dB (11.98 dB for vein graft interposition and 13.80 dB for vein graft surround; p = 0.79). There was no significant difference in hearing outcome between the two techniques. The vein graft interposition technique is preferred for large fenestra or stapedectomy cases and in cerebrospinal fluid gusher cases. The vein graft surround technique is easier to perform and preferred in small fenestra stapedotomy.

Six different surgical method options according to etiology in repair of arteriovenous fistula aneurysms

Aim: This study aims to evaluate the considerations that should be taken into account when choosing a surgical method and the early results of six methods used for repair in patients who underwent surgical repair due to arteriovenous fistula (AVF) aneurysms. Material and Methods: One hundred and five patients who underwent AVF aneurysm repair between 2012 and 2020 were reviewed retrospectively. Methods for surgical repair were used according to the etiology: Plication, Arteriotomy constrictions and plication, Aneurysm excision and creation of a new fistula, Saphenous vein or synthetic graft interposition, End-to-end anastomosis and plication after aneurysm excision, Banding method. Results: Sixty-one of the cases were male and 44 were female. The mean age was 56.6 (27-75) years. The total number of surgeries was 119, including the surgeries and reoperations performed in 2 planned sessions. As surgical method, 44 Plication, 13 Arteriotomy constrictions and plication, 10 Aneurysm excision and creation of a new fistula, 25 Saphenous vein or synthetic graft interposition, 13 End-to-end anastomosis and plication after aneurysm excision and 14 Banding methods were used. AVF flow of 38 patients was measured to be over 1700 ml/min, and 34 of these patients had an arteriotomy length of more than 7 mm. In patients who underwent repair due to high flow rate, an average of 30-65% flow reduction was achieved compared to the preoperative period. In the first postoperative 3 months, 7 (6%) patients required reoperation. Fistula loss did not occur in any of the patients who underwent repair. Conclusion: The etiology of aneurysm, flow rate, aneurysm localization, and the presence of intimal hyperplasia or chronic thrombus are important in choosing an aneurysm repair method. We think that the results will be positively affected if the surgical method is determined according to the association of one or few of these factors.

Common femoral adventitial cystic disease in a young female patient

Adventitial cystic disease (ACD) is a rare condition that typically presents in young healthy men with symptoms of claudication. ACD is characterized by formation of a mucinous cyst within the adventitia of a blood vessel, usually in the popliteal artery, causing compression of the vessel's lumen and leading to reduced flow and symptoms of claudication. We have presented a rare case of ACD of the common femoral artery in a young female patient that was treated successfully with resection and femoral vein graft interposition reconstruction.

Surgical Reconstruction of the Anomalous Left Coronary Artery From the Pulmonary Artery.

The anomalous left coronary artery from the pulmonary artery is a rare congenital disease. Early surgical reconstruction is mandatory to prevent adverse cardiac events. Direct coronary button transfer, vein graft interposition, ligation, and coronary artery bypass construction are the most commonly used techniques. This case report presents a modified technique of Dacron graft interposition and reimplantation anomalous left coronary artery from the pulmonary artery on the ascending aorta.

Delayed revascularization of extremities following vascular injuries: Challenges and outcome

PurposeIn developing countries delayed presentation following major vascular injury is common due to limited vascular trauma units; delay in diagnosis and time lost in transit which pose a major challenge for limb salvage. Aim of this study was to assess limb survival and complications after delayed revascularization of extremity following major vascular injury. Method20 patients, (19 males and 1 female, mean age 31.55 years) with major extremity vascular injury who presented >8 h after vascular trauma were included in this study. All patients had road traffic accidents as the cause of extremity injury. These patients were operated by primary vascular repairs, thrombectomy and/or interposition vein graft along with fixation of concomitant skeletal trauma. ResultsThe commonest vessel injured was popliteal artery. The mean time of limb revascularization was 30.8 h. Limb salvage rate was 95% and there was no perioperative mortality. 9 patients developed postoperative complications including sloughing of leg muscles (4), foot drop (3) pseudo aneurysm (1) and reperfusion injury (1). At 6 months follow-up all the patients were able to walk with full weight bearing and there was no chronic ischemia, pain or sinuses. ConclusionLimb salvage can be achieved with good results in patients with delayed revascularization in selected cases. However; delayed revascularization leads to long and protracted postoperative course with high chances of vascular and neurological complications.

Renoportal Anastomosis and Its Complications: A Complex Case Report

Renoportal anastomosis (RPA) is an effective technique in cases of complex portal vein thrombosis with the presence of a splenorenal shunt. The objective of this report is to describe the possible complications related to RPA. A 50-year-old man with alcohol-related and hepatitis C-related cirrhosis and 2 hepatocellular carcinomas underwent liver transplant. He presented a portal vein thrombosis Yerdel IV, a splenorenal shunt, and another shunt between the inferior mesenteric vein (IMV) and the perirectal plexus. During surgery, the flow of the left renal vein was 891 mL/min, and this rose to 1050 mL/min after IMV clamping. RPA was made through iliac vein graft interposition, and the IMV was ligated. Portal flow was 832 mL/min but drastically decreased because of mesenteric root compression. After finishing the liver transplant, a renoiliac graft percutaneous transhepatic stent was put in place. The patient presented graft dysfunction and acute kidney injury. On postoperative day +18, a second stent was put in place because of a thrombosis in the splenomesenteric confluence. The patient subsequently presented partial distal rethrombosis and a pancreaticoduodenal arteriovenous fistula, which required several embolizations. The patient developed ascites, recurrent gastrointestinal bleeding, and persistent bacterial peritonitis. Finally, a modified Sugiura procedure (without splenectomy) was performed, achieving a portal flow of 1800 mL/min. However, the patient developed sepsis and multiorgan failure, and died on postoperative day +70. Despite long-term patient and graft survival within accepted limits after LT, RPA is a challenging technique not exempt from complications.

Saphenous Vein Interposition Grafts in Lower Extremity Reconstruction: Appraisal of Technique and Case Series.

Summary:Vascular microanastomosis is technically challenging in patients with calcified recipient and donor vessels. Inside-to-outside suturing can prevent plaque rupture and ensure full-thickness intimal approximation. Although this is the preferred technique for anastomosis of atherosclerotic vessels, direct connection of calcified arteries necessitates outside-to-inside suturing on one side of the anastomosis. Furthermore, it is difficult to achieve optimal vessel wall approximation in the setting of luminal size mismatch and rigid vasculature. We previously reported on the use of a saphenous vein interposition graft as a novel technique to achieve a flow-sparing anastomosis in patients with diffuse atherosclerosis who are undergoing free tissue transfer. This study further assesses outcomes of this technique in a series of patients and demonstrates a flap success rate of over 93% in patients with calcified recipient and donor microvasculature.

312.4: Surgical Management of Portal Venous Thrombosis in Patients Undergoing Liver Transplantation Proposed of an Algorithm

Introduction: Portal vein thrombosis (PVT) is common in patients with liver cirrhosis, undergoing liver transplantation (LT); In our environment, this is the first publication with an emphasis on results and surgical strategies.Objectives: It was to review the casuistry of the Guillermo Almenara Irigoyen National Hospital, determine characteristics, types of PVT and surgical management. Materials and Methods: The medical records of cirrhotic patients undergoing LT who presented PVT between March 2000 and June 2021 were analyzed. During this period, 304 liver transplants were performed in 285 patients, 256 adults and 29 pediatric patients; the latter were excluded. Results: We found 46 patients with PVT (17.9%), diagnosed before and during LT, none of malignant aetiology; The most frequent etiologies of cirrhosis were non-alcoholic steatohepatitis (37.4%), alcoholic steatohepatitis (22%), autoimmune hepatitis (AIH) (11%), hepatitis B virus (HBV) (7.4%) and others (11.5%). According to the Yerdel Classification, we find: Grade I: 22 (48%), Grade II: 15 (32.5%), Grade III: 6 (13%) and Grade IV: 3 (6.5%). The surgical strategies used were: thrombectomy in 40 (87.1%); Cavoportal hemitransposition in 2 (4.3%), reno-portal anastomosis with vein graft interposition in 2 (4.3%) and thrombovenectomy plus vein graft interposition in 2 (4.3%). In 3 cases there were re-PVTs (6.5%). We observed that PVT decreased patient survival after LT: One year (81.2%), 3 years (78.4%) and 5 years (78.4%) compared to patients without PVT at 1 year (84.6%) 3 years (82.3%) and 5 years (82.3%). Conclusion: Cirrhotic patients with PVT were clinically more decompensated, survival decreased with a higher degree of PVT. Surgical conduct was similar to other transplant centers; early diagnosis was essential to take an early surgical approach and reduce morbidity and mortality after liver transplantation. A management algorithm for portal vein thrombosis before liver transplantation is proposed. Key words: Portal Vein Thrombosis, Liver Transplantation, Yerdel Classification, Surgical Strategy.

Pediatric Abdominal Malignancies and Intravascular Extension: Contemporary Single-Center Experience

IntroductionInferior vena cava (IVC) thrombus is an uncommon and challenging complication of abdominal malignancies in the pediatric population, which significantly influences the treatment options and clinical outcomes in this population. MethodsIn this review, we present the presentation, treatments, interventions, and outcomes with this clinically and technically challenging oncological finding from a free-standing children's hospital from 2006 to 2017. ResultsFourteen patients with IVC thrombus were identified as having an associated abdominal malignancy. The abdominal malignancies consisted of eight Wilms tumors (63% stage III and 37% stage IV), and one spindle cell sarcoma, neuroblastoma (stage III), kidney clear cell sarcoma (stage III), sclerosing epithelioid fibrosarcoma, hepatoblastoma-epithelial (stage IV), and hepatic embryonal sarcoma (stage IV). 50% of patients were male, 71% White, 29% Black, 7% Hispanic; mean age at diagnosis was 4.09 (SD 2.43) years. CT imaging identified IVC tumor thrombus for 79% of patients, US abdomen complete recorded 14%, and MRI lumbar 7%. 3Out of 14 patients, 13 patients were taken to the operating room with 12 patients undergoing concurrent tumor resection and IVC thrombectomy. Of the remaining patients, one had IVC thrombectomy via femoral cutdown by interventional radiology, and one was noted to have resolution of IVC thrombus with neoadjuvant chemotherapy. Of patients who underwent resection, one required IVC ligation, and one patient required IVC interposition vein graft reconstruction using a right IJ conduit. 60% of patients undergoing thrombectomy received neoadjuvant chemotherapy. Mean time from the diagnosis of IVC tumor thrombus to surgical thrombectomy was 46 (SD 44) days. No operative mortalities were reported. There were five major complications (hemothorax, pulmonary embolisms, seroma, and sepsis) and two minor complications (pneumonia and UTI). With exclusion of patient who underwent IVC ligation, no patients developed signs of IVC compression or recurrent thrombosis after thrombectomy. ConclusionsIVC tumor thrombus can significantly alter the clinical treatment, surgical options, and outcomes of malignant abdominal tumors. Treatment of IVC tumor thrombus included adjuvant chemotherapy, segmental IVC resection with or without reconstruction, thrombectomy with intimal stripping, or resection of the thrombus with part of the IVC wall. Evidence for standard treatment practices for IVC tumor thrombus in the setting of abdominal malignancy is lacking due to the rarity of this finding and the varied clinical presentations.

Biodegradable external wrapping promotes favorable adaptation in an ovine vein graft model

Vein grafts, the most commonly used conduits in multi-vessel coronary artery bypass grafting surgery, have high intermediate- and long-term failure rates. The abrupt and marked increase in hemodynamic loads on the vein graft is a known contributor to failure. Recent computational modeling suggests that veins can more successfully adapt to an increase in mechanical load if the rate of loading is gradual. Applying an external wrap or support at the time of surgery is one way to reduce the transmural load, and this approach has improved performance relative to an unsupported vein graft in several animal studies. Yet, a clinical trial in humans has shown benefits and drawbacks, and mechanisms by which an external wrap affects vein graft adaptation remain unknown. This study aims to elucidate such mechanisms using a multimodal experimental and computational data collection pipeline. We quantify morphometry using magnetic resonance imaging, mechanics using biaxial testing, hemodynamics using computational fluid dynamics, structure using histology, and transcriptional changes using bulk RNA-sequencing in an ovine carotid-jugular interposition vein graft model, without and with an external biodegradable wrap that allows loads to increase gradually. We show that a biodegradable external wrap promotes luminal uniformity, physiological wall shear stress, and a consistent vein graft phenotype, namely, it prevents over-distension, over-thickening, intimal hyperplasia, and inflammation, and it preserves mechanotransduction. These mechanobiological insights into vein graft adaptation in the presence of an external support can inform computational growth and remodeling models of external support and facilitate design and manufacturing of next-generation external wrapping devices. Statement of significanceExternal mechanical support is emerging as a promising technology to prevent vein graft failure following coronary bypass graft surgery. While variants of this technology are currently under investigation in clinical trials, the fundamental mechanisms of adaptation remain poorly understood. We employ an ovine carotid-jugular interposition vein graft model, with and without an external biodegradable wrap to provide mechanical support, and probe vein graft adaptation using a multimodal experimental and computational data collection pipeline. We quantify morphometry using magnetic resonance imaging, mechanics using biaxial testing, fluid flow using computational fluid dynamics, vascular composition and structure using histology, and transcriptional changes using bulk RNA sequencing. We show that the wrap mitigates vein graft failure by promoting multiple adaptive mechanisms (across biological scales).

Aneurısmas arterıales de extremıdad superıor: etıología, manejo y resultado

Upper extremity arterial aneurysms are not common clinical conditions. It may causes ischemic gangrene or limb losses as a result of thromboembolic events due to endothelial damage. In this study, we aimed to investigate the etiology, management, and long-term outcome. A total of 55 upper extremity aneurysms between January 2009 and April 2018 were retrospectively investigated. The mean age was 41 ± 13 years, and the women and men were 13 (23.6%) and 42 (76.4%). The mean follow-up was 43 ± 18 months. The incidence of pseudoaneurysm was higher than the true aneurysm (64.5% vs. 35.5%). 30 (84%) patients who had pseudoaneurysm repaired primerely and 6 (16%) patients had patchplasty. About 58% of the true aneurysm caused by blunt trauma. 4 (21%) true brachial aneurysm patients were required emergency intervention due to distal ischemia. 16 (84.2%) patients operated using by saphenous vein graft. The primary and secondary patency was 87.5% and 93.8%. No limb or life loss occurred during follow-up. Pseudoaneurysms are more common among upper limb aneurysms and they occur mostly by iatrogenic causes. Blunt trauma can be main cause of the true aneurysm. Surgical resection of the aneurysm and interposition of saphenous vein graft provides excellent results in the long-term.

The SELENOT mimetic PSELT promotes nerve regeneration by increasing axonal myelination in a facial nerve injury model in female rats.

Peripheral nerve injury (PNI) is frequent and many patients suffer lifelong disabilities in severe cases. Although the peripheral nervous system is able to regenerate, its potential is limited. In this study, we tested in a nerve regeneration model in rat the potential beneficial effect of a short mimetic peptide, named PSELT, which derives from SELENOT, an essential thioredoxin‐like selenoprotein endowed with neuroprotective and antioxidant activities. For this purpose, the right facial nerve of female Long–Evans rats was axotomized then bridged with a free femoral vein interposition graft. PSELT (1 μM) was injected into the vein immediately and 48 h after the injury, and the effects observed were compared to those found after an end‐to‐end suture used as a gold standard treatment. Whisking behavior, electrophysiological potential, and histological analyses were performed 3 months after injury to determine the effects of these treatments. These analyses revealed that PSELT‐treated animals exhibit a better motor recovery in terms of protraction amplitude and velocity of vibrissae compared to control and end‐sutured nerve animal groups. Moreover, administration of PSELT following injury enhanced muscle innervation, axonal elongation, and myelination of newly formed nerve fibers. Altogether, these results indicate that a PSELT‐based treatment is sufficient to enhance facial nerve myelination and regeneration and could represent a new therapeutic tool to treat PNI.

Usefulness of Interposition Arteriovenous Bundle Grafts in Free Flap Surgery: A Case Series and Systematic Review.

The paucity of reliable recipient vessels adjacent to defects poses a great challenge in free flap reconstruction. Although the use of interposition vein grafts to cover the vascular gap is common, its potential association with higher risks of flap compromise is often reported. Interposition arteriovenous bundle grafts have been introduced as an alternative. This study aimed to evaluate the outcomes of free tissue transfer using interposition arteriovenous bundle grafts and to conduct a systematic review of studies that reported the use of the technique. Patients who underwent free tissue transfer using the interposition arteriovenous bundle graft technique were assessed for flap perfusion-related complications. A systematic review of literature was performed using pooled analysis to calculate the rate of perfusion-related complications. Overall, 14 cases of free flap reconstruction used the interposition arteriovenous bundle graft technique to cover vascular gaps in diverse regions. The most common donor vessel of this graft was the descending branch of the lateral circumflex femoral vessels (mean length, 6.9 cm). All flaps survived except for 1 case of partial flap loss, showing a flap compromise rate of 7.1%. A systematic review identified 13 studies that represented 78 cases using this technique. In the pooled analysis, including the current series, the overall flap survival rate was 95.7%, reporting 4 of 92 cases of flap compromise. The interposition arteriovenous bundle graft technique may help overcome the challenges of pedicle shortage or lack of adjacent recipient vessels in free flap reconstruction.

Anatomical reconstruction of proximal coronary artery stenosis in children.

Timing and method of surgical reconstruction for non-sclerotic proximal coronary artery stenosis, occurring de novo or post-coronary artery transfer, are evolving. We have pursued a technique of anatomical reconstruction of ostial and short segment proximal coronary artery stenosis and atresia in children, using patch plasty or interposition vein graft. Here, we discuss the medium- to long-term outcomes. Nine consecutive children undergoing 10 left main coronary artery reconstructions using autologous great saphenous vein patch (n = 4), autologous pericardium (n = 4), xenopericardium (n = 1) or great saphenous vein interposition graft (n = 1) were retrospectively analysed. Complementary wedge resection of the stenotic coronary ostium was performed in chronic cases. The aetiology of coronary artery stenosis was post-arterial switch operation (n = 6), Takayasu's arteritis (n = 1), idiopathic left main coronary artery atresia (n = 1) and anomalous origin of the left coronary artery from the pulmonary artery (n = 1). The median age and weight at operation were 0.15 (range 0.01-13.1) years and 4.4 (range 3-13.1) kg, respectively. Survival was 100% at the medi follow-up of 12.6 (range 1-19.2) years. All patients showed normal left ventricular ejection fraction on transthoracic echocardiogram. In 1 patient, kinking of the proximal left circumflex artery resulted in non-significant obstruction. In all other cases, follow-up catheter angiography revealed unobstructed coronary arteries. Cardiac magnetic resonance tomography showed no significant perfusion deficit in any child. Anatomical reconstruction of the proximal left coronary artery using autologous saphenous vein may allow optimal restoration of physiological coronary blood flow, keeping the option of future coronary bypass operation open.

True Brachial Artery Aneurysm in Patients with Previous Arterio-Venous Fistula Ligation and Immunosuppressant Therapy for Renal Transplantation: Case Report and Literature Review.

Background/Objective: Brachial artery aneurysm (BAA) is a serious complication in patients with previous arterio-venous fistula (AVF), renal transplantation (RT), and immunosuppressive regimens. Until now, there has been no standard of care for these patients, especially for patients undergoing chronic dialysis and immunosuppressive treatment. The aim of this study was to investigate data from the literature regarding these patients and to suggest recommendations for the best approach to their treatment. Methods: A review of the literature was performed by searching the PubMed database in the English language. The review was accompanied by two case reports. A total of 24 articles with different variables—demographics, renal transplantation, aneurysm size, and type of surgery—were subjected to the review. In addition, two cases are reported. Conclusion: This review suggests that the best treatment for these patients is open surgery, with aneurysmectomy and graft interposition. Results: All patients had RT. The age of patients ranged from 26–77 yo, with a male predominance. The majority had an AVF ligated after RT. The main clinical symptoms were pain, swelling, and pulsatile mass (66%). All patients, except one, were treated through open surgery. The first option for treatment was reversed saphenous vein graft interposition (36%), followed by ePTFE graft (16%).

Pedicled thoracodorsal artery perforator flap in the soft-tissue reconstruction of an acute traumatic cubital fossa defect

Complex cubital fossa injuries with bony and vascular injuries are not an uncommon clinical presentation after trauma to the elbow. The revascularization of the upper limb by brachial artery repair with the venous graft is paramount, followed by immediate cover with a sturdy flap to salvage the limb. The use of local muscle and fasciocutaneous flaps is limited in the setting of vascular injury. The pedicled latissimus dorsi muscle flap and abdominal flaps are routinely used with few advantages. This article describes the use of a pedicled thoracodorsal artery perforator flap in the management of acute traumatic cubital fossa defect. A retrospective observational study was performed from September 2015 to December 2020 with patients who underwent the pedicled TDAP flap as a soft-tissue cover of cubital fossa injuries primarily. Patient variables, including the size of defect and flap, the number of perforators, the complications, and the outcome, were recorded. Eleven patients were included in the study. The majority of the patients were males (n=10) and presented with a history of trauma in a road traffic accident (n=6) or because of a fall from height (n=4). All of them (n=11) had some form of bony injury. Seven patients in this group required brachial artery repair with an interposition vein graft successfully covered with a TDAP flap. There was a constant dominant musculocutaneous perforator about 10-13cm from the apex of the axilla. At discharge, all flaps had settled well. On follow-up ranging from 2 months to 2 years, the patients reported satisfactory outcomes.