Shunt Patency Research Articles

Feasibility of a No-Implant Approach to Interatrial Shunts: Preclinical and Early Clinical Studies

BackgroundHeart failure with preserved ejection fraction represents a major unmet clinical need with limited treatment options. Recent device therapies under investigation have focused on decompression of the left atrium through an implantable interatrial shunt. Although these devices have shown favorable safety and efficacy signals, an implant is required to maintain shunt patency, which may increase the patient risk profile and complicate subsequent interventions requiring transseptal access. MethodsThe Alleviant System is a no-implant approach to creating an interatrial shunt using radiofrequency energy to securely capture, excise, and extract a precise disk of tissue from the interatrial septum. Acute preclinical studies in healthy swine (n = 5) demonstrated the feasibility of the Alleviant System to repeatably create a 7 mm interatrial orifice with minimal collateral thermal effect and minimal platelet and fibrin deposition observed histologically. ResultsChronic animal studies (n = 9) were carried out to 30- and 60-day time points and exhibited sustained shunt patency with histology demonstrating completely healed margins, endothelialization, and no trauma to adjacent atrial tissue. Preliminary clinical safety and feasibility were validated in a first-in-human study in patients with heart failure with preserved ejection fraction (n = 15). All patients demonstrated shunt patency by transesophageal echocardiographic imaging at 1, 3, and 6 months, as well as cardiac computed tomography imaging at 6-month follow-up timepoints. ConclusionsCombined, these data support the safety and feasibility of a novel no-implant approach to creating an interatrial shunt using the Alleviant System. Continued follow-up and subsequent clinical studies are currently ongoing.

Safety and efficacy of TIPS combined with iodine-125 seed strands in the treatment of patients with hepatocellular carcinoma combined with portal vein tumor thrombosis

Objective: To study the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) combined with iodine-125 (125Ⅰ) seed strands implantation in patients with hepatocellular carcinoma combined with portal vein tumor thrombosis. Methods: 25 cases with diffuse intrahepatic tumor combined with tumor thrombus type Ⅲ/Ⅳ requiring TIPS were simultaneously implanted with 125Ⅰseed strand. Tumor thrombus was controlled with 125I seed implantation brachytherapy to keep the TIPS pathway unobstructed, reduce the portal vein pressure, and observe the changes in the cause of death of the patients. During the same period, 30 cases without TIPS and seed strand implantation were used as controls. Data between groups were compared using t-test, Chi-Squared test or Fisher's exact test. Results: TIPS combined with 125Ⅰ seed strand implantation was safe in patients with diffuse hepatocellular carcinoma combined with type III/IV portal vein tumor thrombus, and 92.0% (23/25) of the patients maintained unobstructed TIPS pathway. Compared with the control group, patients in the treatment group died of fewer lead-related complications, and most died from chronic liver failure (84.0% vs. 56.7%, χ2 = 4.771, P=0.029). The incidence of upper gastrointestinal bleeding was significantly decreased (12.0% vs. 46.7%, χ2 =7.674, P=0.006) and ascites severity was significantly improved (mild 40.0% vs. 16.7%, moderate 52.0% vs. 20.0%, severe 8.0% vs. 46.7%, χ2 =13.246 , P=0.001). Conclusions: TIPS combined with 125Ⅰ seed strand implantation is safe and feasible in patients with diffuse intrahepatic tumor combined with tumor thrombus type Ⅲ/Ⅳ. Moreover, it can effectively keep the shunt patency and reduce portal vein pressure, thereby reducing the incidence of upper gastrointestinal bleeding and improving the degree of ascites. TIPS combined with 125Ⅰ seed strand implantation may be used as a standard treatment modality for patients requiring TIPS therapy combined with tumor thrombus type Ⅲ/Ⅳ.

A Narrative Review of Postoperative Anticoagulation Therapy for Congenital Cardiac Disease.

Congenital heart disease encompasses a range of cardiac birth defects. Some defects require early and complex surgical intervention and post-operative thromboprophylaxis primarily for valve, conduit, and shunt patency. Antiplatelet and anticoagulant management strategies vary considerably and may or may not align with recognized consensus practice guidelines. In addition, newer anticoagulant agents are being increasingly used in children, but these medications are not addressed in most consensus statements.This narrative review evaluated the literature from 2011 through 2021 on the topic of postoperative thromboprophylaxis after congenital heart disease operations. The search was focused on the descriptions and results of pediatric studies for replacement and/or repair of heart valves, shunts, conduits, and other congenital heart disease operations. Wide variability in practice exists and, as was true a decade ago, few randomized controlled trials have been conducted. Aspirin, warfarin, and perioperative heparin remain the most commonly used agents with varying dosing, duration, and monitoring strategies, making comparisons difficult. Only recently have data on direct oral anticoagulants been published in children, suggesting evolving paradigms of care. Our findings highlight the need for more research to strengthen the evidence for standardized thromboprophylaxis strategies.

The challenges of ascites management: An Indian perspective.

Content available: Author Interview and Audio Recording.

PO-658-05 CLINICAL UPDATE FOR NO-IMPLANT INTERATRIAL SHUNT FOR HEART FAILURE WITH PRESERVED EJECTION FRACTION

Heart failure with preserved ejection fraction (HFpEF) represents a major unmet clinical need with limited treatment options. Implantable interatrial shunt devices have shown favorable safety and efficacy signals; however, they require permanent implantation to maintain shunt patency.

The rex shunt for left portal vein reconstruction during hepatectomy for malignancy using of rex-shunt in adults for oncoliver surgery.

Immediate portal reperfusion is mandatory following hepatectomy combined with portal vein (PV) resection. This retrospective study analyzes the feasibility and the outcomes of the Rex shunt (RS) for reconstruction of the left portal vein (LPV) and reperfusion of the remnant left liver or lobe following hepatectomy for cancer combined with resection of the PV in adult patients. From 2018 to 2021, an RS was used in the above setting to achieve R0 resection or when the standard LPV reconstruction failed or was deemed technically impossible. There were 6 male and 5 female patients (median age, 58years) with perihilar cancer (5 cases) or miscellaneous cancers invading the PV (6 cases). A major hepatectomy was performed in 10/11 patients. The RS was indicated to achieve R0 resection or for technical reasons in 8 and 3 cases, respectively, and was feasible in all consecutive attempts with (10 cases) or without an interposed synthetic graft (1 case). Two fatal complications (PV thrombosis and pulmonary embolism) and three non-severe complications occurred in four patients within 90days of surgery. Two patients died of tumor recurrence with a patent RS at 13 and 29months, and 7 were recurrence free with a patent shunt with a follow-up of 1 to 37months (median, 15months). In case of remnant left liver or lobe following hepatectomy combined with resection of the PV, the RS may help to achieve R0 resection and is a valuable option to perform technically satisfying portal reperfusion of the remnant left liver or lobe.

First in Human Experience of a Novel No-implant Interatrial Shunt Device for Heart Failure with Preserved Ejection Fraction

<h3>Introduction</h3> Chronic heart failure withpreserved ejection fraction (HFpEF) comprises approximately 50% of all heartfailure diagnoses and currently has limited proven drug or device therapies. Symptomsof HFpEF, particularly dyspnea, are primarily mediated by elevated left atrialpressure. Creation of an interatrial shunt to permit left-to-right atrial flowmay improve dyspnea and other patient outcomes by mediating left atrialdecompression, thereby reducing diastolic filling pressures and improvingexercise tolerance and quality of life. Recently, implantable interatrial shuntdevices have demonstrated promise as a therapeutic option for HFpEF. Deliveringthe physiologic benefit of an interatrial shunt without a permanent cardiacimplant may have clinical advantages. We report the 6-month outcomes ofpatients treated with an implant-free interatrial shunt device. The purpose ofthis first in human study was to evaluate the safety, feasibility anddurability of the percutaneous atrial septectomy enabled by the AlleviantMedical device. <h3>Methods</h3> Key inclusion criteria were NYHAclass II (with history of greater than class II), III and ambulatory class IV,echocardiographic evidence of diastolic dysfunction, elevated peak PCWP andnormal right atrial pressure during supine ergometry. The procedure utilizedfemoral vein access and standard transseptal catheterization techniques. Thedevice was utilized to capture, excise, and remove a precisely sized section ofthe atrial septum to create a therapeutic shunt under fluoroscopic andechocardiographic guidance. <h3>Results</h3> 10 patients were enrolled inthe study. Mean age was 67 ± 8 years. Mean LVEF was 61.1 ± 10.1%. 4 patientswere NYHA class II; 6 were NYHA class III at baseline. The procedure wassuccessful with shunt creation confirmed in all patients (mean shunt size 6.8 ±1.0 mm) and no device or procedure-related adverse events. At 30 days, meanpeak exercise PCWP was reduced significantly (8 ± 10 mmHg, p=.026). At 6 months,NYHA status improved by one class in 7 patients, worsened by one class in 1 patientand did not change in 2 patients. All shunts were open at 6 months with left-to-rightflow and stable size confirmed via TEE (mean shunt size 6.8 ± 0.7 mm across ninepatients). At 6 months, mean 6MWT increased (146 ± 76 m, p<.001), ProBNPdecreased (687 ± 234 pg/ml, p<.001), and KCCQ score increased (24 ± 15,p<.001). No device or procedure-related serious adverse events occurredthrough 6 months. <h3>Conclusions</h3> This initial experiencedemonstrates that percutaneous creation of an implant-free interatrial shunt inpatients with HFpEF is safe and feasible with sustained clinical and hemodynamicimprovement and shunt patency through 6 months. Subsequent clinical studies tocontinue clinical evidence development are currently underway.

Clinical Outcomes of Transjugular Intrahepatic Portosystemic Shunt (Tips) Creation Using Fluency Versus Viatorr Stent-Grafts: A Single-Centre Retrospective Study.

To investigate the effects of transjugular intrahepatic portosystemic shunt (TIPS) creation using Fluency versus Viatorr stent-grafts on the long-term clinical outcomes. This was a single-center retrospective study from January 2010 to October 2021 in 213 patients receiving TIPS with Fluency (Fluency group, n = 154) versus Viatorr (Viatorr group, n = 59) stent-grafts. Inclusion criteria were: age > 18years old and TIPS creation for variceal hemorrhage. Exclusion criteria were: age > 80years old, concomitant chronic heart or lung disease, active tuberculosis or human immunodeficiency virus infection, extrahepatic malignancy, alcohol dependence, TIPS created outside of our hospital, without any follow-up data, or decline to participate. The primary outcome was primary patency rate and its associated risk factors. The 5-year cumulative primary patency rate was significantly higher in Viatorr group than in Fluency group (89.0% vs. 19.6%, p < 0.001), whereas the 5-year cumulative transplant-free survival rate (62.3% vs. 62.2%, p = 0.636) was comparable between two groups. Cox-regression models revealed that group (hazard ratio [HR]4.029, 95% confidence interval [CI] 1.486-10.927, p = 0.006), use of bare stents (HR 3.307, 95% CI 1.903-5.747, p < 0.001), and baseline portal vein thrombosis (HR 0.248, 95% CI 0.149-0.412, p < 0.001) were significantly associated with shunt patency. Incidences of adverse events were not significantly different between two groups (p > 0.05). TIPS creation using Viatorr stent-grafts is superior to using Fluency stent-grafts in terms of higher long-term primary patency rate but similar transplant-free survival rate.

Common indications and impact on clinical management of overnight, inpatient transthoracic echocardiograms performed by pediatric cardiology fellows

BackgroundOne of the core competencies of pediatric cardiology fellowship training is to perform and interpret transthoracic echocardiograms. Each institution is responsible for developing a curriculum surrounding this skill, yet there is little literature about the most common indications and the utility of these studies. ObjectivesThe aims of this study are to determine the most common indications for overnight, inpatient transthoracic echocardiograms in pediatric patients performed by fellows and to evaluate their impact on clinical management. MethodsRetrospective chart review was completed for all transthoracic echocardiograms performed overnight by pediatric cardiology fellows during a one-year period. Study indication, result, and ordering hospital unit were obtained. Transthoracic echocardiograms impact was classified based on documentation in the medical record. ResultsTwo hundred and twenty-five overnight transthoracic echocardiograms were performed on 186 patients; 46% had underlying structural heart disease. The most common indication was for assessment of left ventricular function (40.9%). The Heart Center (combined cardiac intensive care unit and step-down unit) was the most common ordering unit (40%). Fifty-four percent of studies were documented in the medical record as having impacted clinical decision-making. The indications resulting in the highest clinical impact were evaluation of shunt patency (100%) and confirmation of prenatally diagnosed congenital heart disease (86%). Clinical impact of overnight, inpatient transthoracic echocardiograms was higher in patients with known heart disease compared to those without (67% vs 43%). ConclusionPediatric cardiology fellow education should emphasize early training for assessment of left ventricular function and high impact indications in patients with congenital heart disease. Impact of overnight transthoracic echocardiograms is highest when used in children with underlying heart disease.

Use of caudal pancreatectomy as a novel adjunct procedure to proximal splenorenal shunt in patients with noncirrhotic portal hypertension: A retrospective cohort study.

Backgrounds/AimsProximal splenorenal shunt (PSRS) is considered a one-time treatment for noncirrhotic portal hypertension (NCPH) to prevent recurrent upper gastrointestinal (UGI) hemorrhage and long-term complications. Long-term shunt patency is necessary to achieve these. The lie of the shunt is a contributing factor to early shunt thrombosis. We investigated the role of resection of the distal tail of pancreas (caudal pancreatectomy [CP]) in improving the lie of shunt and decreasing shunt thrombosis.MethodsThis was a retrospective cohort study of patients with NCPH who underwent PSRS between 2014-2020 in JIPMER, Puducherry, India. CP was performed in patients with a long tail of pancreas, with the tip of pancreatic tail extending up to splenic hilum on preoperative CT. Perioperative parameters and shunt patency rate of patients who underwent PSRS with CP (Group A) were compared with patients undergoing conventional PSRS (Group B). Statistical analysis was performed using the Mann-Whitney U test and χ2 test.ResultsEighty four patients with NCPH underwent PSRS (extrahepatic portal vein obstruction = 39; noncirrhotic portal fibrosis = 45). Blood loss was lower (p = 0.002) and post-shunt fall in portal pressure higher (p = 0.002) in Group A. Shunt thrombosis rate was lower (p = 0.04) while rate of complete variceal regression (p = 0.03) and biochemical pancreatic leak (p = 0.01) were higher in Group A.There was no clinically relevant pancreatic fistula in either group.ConclusionsCP is a safe and useful technique for reducing shunt thrombosis after PSRS in patients with NCPH by improving the lie of shunt.

Anesthetic management of a single-ventricle pediatric patient with scoliosis: A case report

Single ventricle is a complex cardiac disease which carry high morbidity and mortality and the average 3 years survival rate without Fontan procedure was approximated to be 75%. The most common etiologies are: hypoplastic left heart syndrome and tricuspid atresia. When those patient plan to go for surgery, it’s very essential for anesthetist to understand how the physiology is affected rather than etiology. BT shunt patency, right ventricular function and pulmonary artery pressure should be evaluated before any procedure under anesthesia. Scoliosis corrective surgery is a procedure that has its special considerations related to restrictive pulmonary disease, prone positioning, and major bleeding that may occur, which altogether will add to the risk when being conducted in a single-ventricle patient and will necessitate vigilance and special care during monitoring intraoperatively. Here, we report a simple way to monitor the transpulmonary pressure gradient through two central lines in the femoral and jugular veins as part of the patient’s anesthesia management.

Functional side-to-side splenorenal shunts to treat extrahepatic portal vein thrombosis in children

BackgroundSurgical shunts are commonly used to manage complications resulting from extrahepatic portal vein thrombosis (EHPVT) in children. We describe a single-center experience utilizing a functional Side-to-Side Splenorenal Shunt (fSRS), created using either an enlarged inferior mesenteric vein (IMV) or left adrenal vein (LAV). MethodsPediatric patients with isolated EHPVT who were poor candidates for a Rex shunt and who underwent a fSRS procedure at our institution between 2003 and 2020 were reviewed. The pre/post shunt portosystemic gradient change, rates of early and late complications, postoperative shunt patency, and mortality were evaluated. ResultsTwelve EHPVT patients (mean age of 6.1 years) underwent a fSRS procedure. The mean portosystemic gradient change for the cohort was −11.7 mmHg (±4.9). There were no cases of recurrent variceal bleeding or episodes of shunt thrombosis reported after fSRS procedures. ConclusionsSurgical shunts continue to be an important adjunct in the treatment of complications related to EHPVT. The functional Side-to-Side Splenorenal Shunt is a safe alternative that is easy to perform, involves minimal dissection and requires only a single anastomosis.

Transmembrane stent placement for cor triatriatum dexter in six dogs

ObjectivesReport the long-term outcomes following transmembrane stent placement as a therapy for Cor Triatriatum Dexter (CTD). Materials and methodsRetrospective case series including six dogs with CTD treated with transmembrane stent placement. Follow-up information was obtained including the persistence of presenting clinical signs, additional therapies required, and survival. ResultsThe median follow-up time was 24 months (range 15–76 months). Long-term outcome was deemed excellent in four dogs (67%), good/fair in one dog (17%), and poor in one dog (17%). Three dogs had persistence of clinical signs of variable severity. These three dogs were Labrador Retrievers or their crosses with varying degrees of tricuspid valve dysplasia (TVD), two of which also had a right to left shunting patent foramen ovale (PFO). One of these three dogs died 23 months post-stent placement during attempted open-heart repair of the TVD and PFO. Another is alive 15 months post-operatively stable on medical therapy for right-sided congestive heart failure secondary to TVD. The final dog demonstrated improved but persistent mild exercise intolerance up to 76 months post-operatively associated with mild TVD and a concurrent PFO. ConclusionsTransmembrane stent placement for CTD is a viable long-term treatment option with improvement or resolution of clinical signs. In the presence of concurrent congenital heart disease, specifically Labradors with TVD, additional therapies may be necessary with a corresponding impact on prognosis.

Use of the Rex Shunt in Adults for Left Portal Vein Reconstruction

Introduction: To report an expanded use of Rex shunt (RS) for portal vein (PV) reconstruction in adults. The RS was developed to treat children with extrahepatic portal vein thrombosis (EHPVT) following liver transplantation or with a healthy liver. Method: An RS was used to achieve portal reperfusion during various liver surgeries when a standard porto-left portal anastomosis was deemed technically unsatisfactory or incompatible with right-sided R0 onco-surgical resection. Results: This study involved 5 male and 6 female patients (median age, 59 years). The RS was feasible in all 11 consecutive attempts, including hepatectomy for malignancy combined with PV resection in 9 (82%) patients where the left lobe or liver was left in place.A reinforced Gore-Tex graft was used in 10 patients and an allogenic iliac vein was used in 1 patient.Within 90 days, 1 patient with a patent shunt had died of pulmonary embolism, and 1 patient had died of diffuse PVT with multiple organ failure.In 4 patients, postoperative complications included ascites, biliary fistula, and shunt thrombosis.At a median 13.5-month follow-up, 7 patients with a patent shunt remained alive. A systematic review of RS in adults identified 11 cases in 8 reports performed mainly for EHPVT (9 patients). In 2 patients, postoperative complications involved transient ascites and abdominal bleeding requiring surgical revision.Postoperative mortality was nil. The median long-term patency rate was 24 months. Conclusion: Use of the RS in adults is straightforward, offering a supplementary technical option for left portal reconstruction in patients with malignancy or EHPVT,provided the downstream portal system is normal.

SURGICAL TREATMENT IMMEDIATE RESULTS OF LOWER LIMBS CHRONIC CRITICAL ISCHEMIA IN IMMULTANEOUS DIRECT AND INDIRECT REVASCULARIZATION

The aim: To assess the immediate results of autovenous femoral-tibial shunting in combination with rotary osteotrepanation of the tibia by studying changes in the transcutaneous ptO2 tension in the tibia and foot tissues depending on the revascularization of the tibial arteries. Materials and methods: We analyzed the treatment of 69 patients with obliterating atherosclerosis of the vessels of the lower extremities. According to the degree of ischemia of the lower extremities, the patients were distributed as follows: III A degree of ischemia - 20 (29%), III B - 28 (40.6%), IV - 21 (30.4%) patients. All patients had atherosclerotic lesions of the popliteal-tibial segment of the great arteries with preserved central blood flow in the aorto-iliac segment. Results: Occlusion of the anterior tibial artery was recorded significantly more often than the peroneal artery (72% and 42%, respectively, p = 0.05), but with the same frequency compared to the posterior tibial artery (68%, p = 0.61). The lesion of two or three arteries of the lower leg was recorded more often than occlusion of one (n = 51; 73.9% and n = 18; 26.1%). Occlusive-stenotic lesion of the popliteal artery was observed in 54 (78.2%) patients. The highest incidence of lesions of the tibial arteries was observed in the basin of the anterior tibial artery in 28 (40.6%) patients. Combined lesions of the anterior tibial artery and posterior tibial artery were diagnosed in 19 (27.5%) patients. Limited lesions of the posterior tibial artery were found in 15 (21.7%) patients. The combination of lesions of the posterior tibial artery and peroneal artery was diagnosed in 7 (10.2%) patients. Conclusions: 1. The patency of the femoral-tibial autovenous shunt during the year was 71%. High limb amputation was performed in 29% of patients. 2. According to CT data, the localization of trophic changes on the foot during critical ischemia of the lower extremities corresponds to the affected segment of the arterial angiosome, which supplies the corresponding area with blood. 3. After femoral-tibial autovenous bypass grafting, the highest levels of transcutaneous oxygen tension were observed in the basin of the posterior tibial artery and peroneal artery, and the lowest indicators of transcutaneous oxygen tension were observed in the basin of the anterior tibial artery. 4. During femoral-tibial autovenous shunting operations in combination with rotary osteotrepanation, the transcutaneous oxygen tension indices increased threefold in the angiosomal basin of the posterior tibial artery and peroneal artery, and twofold in the angiosomes of the dorsum of the foot and sole.

CLINICAL CASE: CORONARY ARTERY BYPASS GRAFTING IN A PATIENT WITH CORONARY ARTERY DISEASE ACCORDING TO THE MIDCAB TECHNIQUE

Abstract: Today the main operations of myocardial revascularization are coronary artery bypass grafting (CABG) with artificial circulation (CI) and beating heart surgery, as well as balloon angioplasty and stenting. However, the modern standard for the provision of surgical care to patients with multivessel atherosclerotic coronary artery disease is CABG under cardiopulmonary bypass (IC), introduced into clinical practice in the 60s of the XX century. This approach is convenient for surgeons and allows for good visualization of all parts of the heart and the ascending aorta with a motionless bloodless surgical field in the area of formation of distal anastomoses. At the same time, the required amount of time for performing anastomoses is provided by a sufficient level of myocardial protection. This method has a statistically significant patency of shunts in the long-term period after the intervention [1,3]. On the basis of numerous studies of the classical method of CABG in conditions of IC, indications were developed, the basic principles and approaches were formulated in patients with coronary heart disease (IHD) [2]. The classical method of performing CABG always corresponds to the traumatic sternotomy approach, and also has a number of significant negative consequences caused by the use of the IC device: systemic inflammatory response, micro- and macroembolism of the brain, as well as other organs and systems, with which renal, respiratory and other complications of the postoperative period [2,3]. To prevent or reduce these negative effects on the body, especially in the presence of concomitant pathology, as well as in elderly patients, low-traumatic techniques are currently used without the use of an infrared device. These methods include the so-called Off-Pump Coronary Artery Bypass (OPCAB). Studies have shown that CABG surgery on a beating heart without the use of a heart-lung machine is safer, including the number of neurological complications is statistically significantly lower, and the rehabilitation process for such patients is shorter, which is reflected in the economic aspects [4, 5] ... All over the world, every year more and more direct myocardial revascularization operations are performed on a beating heart. So in large centers of the USA, Europe and Russia, according to the literature, up to 70% of cases are performed using the ORSAV technique [6]. We present a description of a clinical case of multiple beating heart bypass surgery using the MIDCAB mini access, performed in our center to a patient with concomitant pathology in the form of chronic heart failure and dyscirculatory encephalopathy. Good results were obtained, both intraoperatively and postoperatively. The results of such an intervention were analyzed in terms of the presence of pain in the postoperative period, the patient's quality of life, and from the point of view of economic feasibility. The method was adopted at the Republican Specialized Scientific and Practical Medical Center for Cardiology of the Karshi branch.

Rex Shunt for Portal Vein Thrombosis After Pediatric Living Donor Liver Transplantation

BackgroundPortal vein thrombosis (PVT) after pediatric liver transplantation (LT) is a common but grave complication which could eventually result in life-threatening portal hypertension. A “Rex” shunt between the superior mesenteric vein and the Rex recess of the liver has been reported to be a treatment option for extrahepatic portal vein obstruction; however, its application to living donor liver transplantation (LDLT) is limited due to the availability of appropriate vein grafts. In this study, we retrospectively evaluated the effectiveness of Rex shunt as an option for the treatment of PVT after pediatric LDLT.Case ReportThree children underwent the Rex shunt for early (n=2) and late (n=1) PVT after LDLT using the greater saphenous vein (n=2) and the external iliac vein (n=1) from the parents who previously donated their livers.Two of the 3 children are free from symptoms with patent shunt grafts at 14 years after the procedures. One child died at 30 days after LDLT due to repeated episodes of PVT, which finally led to hepatic infarction.ConclusionsThe Rex shunt is feasible to treat PVT after LDLT. However, additional surgical insults to the living donor need further discussion.

Experience in treating patients with diabetes and anastomotic false aneurysm after reconstructive interventions in the aortic-femoral segment

The purpose of the work isto analyze and improve the results of treatment of patients with diabetes and anastomotic false aneurysm (FA) after reconstructive interventions. Materials and methods. The results of diagnostic examinations in 79 patients with 93 false anastomotic aneurysms were analyzed, the criteria of wound complication (hematoma, infiltrate), patency of shunts, bleeding, heart attack, stroke were evaluated. Among the patients there were 75 (94.9 %) men and 4 (5.1 %) women aged 40—75 years (mean age — (58.4 ± 2.9) years). 69 (87.3 %) patients underwent surgery for atherosclerotic lesions of the pelvic vessels and lower extremities, including 43 (54.4 %) patients with diabetes, 3 (3.8 %) — for abdominal aortic aneurysm, 4 (5.1 %) — after vascular injury, 3 (3.8%) — due to nonspecific aortic arteritis. A total of 79 patients underwent 93 reconstructive interventions. Results and discussion. The time of onset of clinical symptoms (pain, pulsation), which give reason to suspect the occurrence of FA, ranged from 8 days to 19 years: in 15 patients — less than 1 year, in 59 — up to 10 years, in 5 — up to 20 years. The average duration of FA formation after surgery is 62.5 months. The absence of pathological changes in the area of the proximal anastomosis and the presence of adequate outflow pathways in most cases allow us to limit the reconstruction of the distal anastomosis. Conclusions. Early diagnosis and surgical tactics for false anastomotic aneurysms in patients with diabetes can prevent complications and improve the results of surgical treatment. The optimal type of surgery for false aneurysms is their removal with re-prosthesis of the affected segment, which allows to save the limb and the patient's life. The use of modern pharmacological agents allows to reduce the progression of atherosclerosis, which is the main cause of false aneurysms. Dynamic ultrasound monitoring is required for patients who have undergone reconstructive vascular surgery.

Assessment of superior cavo-pulmonary anastomoses (Glenn shunt) by cardiac magnetic resonance imaging in comparison with multi-slice computed tomography

BackgroundMulti-slice computed tomography (MSCT) angiography is the gold standard imaging modality to evaluate the patency of Glenn shunt and the presence of veno–veno collaterals. The goal of this study is to evaluate the ability of two cardiac magnetic resonance imaging (MRI) techniques to assess the patency of Glenn shunt and the presence of veno–veno collaterals compared to MSCT angiography.ResultsPatients with Glenn shunt had MSCT angiography and cardiac MRI using two techniques: TWIST (Time-resolved angiography With Stochastic Trajectories) and the three-dimensional (3D) post-contrast whole heart techniques. MSCT angiography and cardiac MRI images were post-processed for quantitative and qualitative assessment of Glenn shunt and veno–veno collaterals. Our study included 29 patients (17 male, 59%) with Glenn shunt, the median age was 22 years (range 3–36 years). 3D post-contrast whole heart images give similar results compared to MSCT angiography results in the evaluation of Glenn shunt and veno–veno collaterals, 100% agreement in Glenn shunt visualization and agreement was 86.2% in the detection of veno–veno collaterals with a perfect agreement (kappa = 1) as regards their proximal connection to superior vena cava (SVC). While TWIST showed lower agreement compared to MSCT angiography results, 87.5% agreement in Glenn shunt visualization and agreement was 68.9% in the detection of veno–veno collaterals with poor agreement (kappa = 0.266) as regards their proximal connection to SVC.Conclusions3D post-contrast whole heart MRI images have similar results as MSCT angiography in the evaluation of superior cavo-pulmonary anastomosis and can be a good and safer alternative to MSCT angiography.

Digital Ocular Compressions Reduce Intraocular Pressure in Eyes With Tube Shunts.

Digital ocular compressions (DOCs) decrease intraocular pressure in eyes with tube shunts by significantly greater magnitude and duration when compared with fellow eyes without filtering surgery. DOCs are commonly used by glaucoma surgeons to reduce intraocular pressure (IOP) in the early postoperative period. Little is known, however, about the effects of DOC in eyes with tube shunts. We therefore examined these effects in eyes with long-established, functional glaucoma tube shunts. In this masked prospective study, adult subjects with primary open angle glaucoma and an Ahmed tube shunt in only 1 eye were recruited. After obtaining baseline IOP with Goldmann applanation tonometry a single transpalpebral DOC was applied to each eye (in random order). Postcompression IOP was measured after 10, 20, 30, 60, 90, 120, 150, 180, 210, and 240 minutes or until the measured IOP returned to baseline. The fellow (nonsurgical) eye was a control. Magnitude and duration of IOP reduction were evaluated using Kaplan-Meier analysis. The pressure applied to eyes in each cohort was standardized through the use of a force sensitive resistor and impulse was analyzed for differences. Twenty-two eyes of 11 patients underwent DOC. There was no significant difference in the impulse applied to eyes in each cohort (P=0.6). A mean initial IOP reduction of 5.36 mm Hg occurred in tube shunt eyes and 2.55 in control eyes (P=0.014). Log-rank analysis demonstrated longer survival in the tube shunt group (P=0.049). DOC is an effective method for transiently reducing IOP in eyes with long-established, patent tube shunts for about an hour. To maintain this decrease in pressure, compressions will have to be performed on a scheduled basis.