Postoperative Occlusion Research Articles

3D planning in mandibular fractures using CAD/CAM surgical splints — A prospective randomized controlled clinical trial

This randomized controlled trial assessed the role of CAD/CAM splints in achieving anatomic reduction of fractured fragments and ideal occlusion, in comparison with conventional splints.Patients diagnosed with displaced mandibular fracture and post-traumatic malocclusion were allocated to study and control groups by simple randomization. A standardized surgical approach was followed to expose the fractures. Reduction of fractures was carried out using CAD/CAM and conventional splints in the study and control groups, respectively. The parameters assessed were: occlusion, interfragmentary separation, fit of the splint, patient comfort, and surgeon comfort. Mann-Whitney U tests were used to compare the study and control groups. To compare the groups pre- and post-intervention Wilcoxon signed rank tests were used. Chi-square tests were applied for proportion comparisons. The sample consisted of 30 patients.The study group demonstrated superior clinical outcomes with regards to intraoperative reduction of fracture (p < 0.001; mean – 3.93, SD – 1.43), and to achieving intraoperative occlusion (p = 0.483) and postoperative occlusion (p = 0.224). Statistically significant improvements in both patient comfort (p < 0.001; mean – 0.20, SD – 0.41) and surgeon comfort (p < 0.001) were found in the study group. In conclusion, CAD/CAM splints improve precision in fracture reduction and restoration of occlusion through a simple fabrication process.

Open Reduction and Internal Fixation of Unilateral Mandibular Condylar Base and Neck Fractures Using a Lambda Plate: Selection Criteria for Application

The aim of this study was to evaluate the clinical, radiologic, and functional outcomes in a retrospective cohort study of patients with condylar base and neck fractures treated with open reduction and internal fixation via lambda plates to define selection criteria for their application. Eleven patients underwent open reduction and internal fixation using lambda plates for osteosynthesis of condylar base and neck fractures. The mean follow-up period was 8months. All kinds of complications were recorded. Postoperative maximum jaw opening and occlusion were determined. Pain on palpation of the joint area, pain on movement, and muscle pain were examined. The criteria for the intraoperative selection of a lambda plate were recorded. Positioning and fixation of lambda plates were feasible in all cases. A condylar neck fracture with limited bone surface on the proximal fragment for internal fixation prevailed as the primary indication for the selection of a lambda plate. Avoiding extensive soft tissue stripping at the proximal fragment when using a transoral endoscopically assisted approach in cases of condylar base fractures also was a selection criterion.The overall complication rate was low. The indications for lambda plates for internal fixation of condylar fractures are neck fractures with limited bone surface along the proximal fragment for internal fixation. Application of the plate through a transoral endoscopic approach to avoid extensive soft tissue stripping at the proximal fragment is favorable in high condylar base fractures.

Stent assisted coiling versus non-stent coiling for the management of ruptured intracranial aneurysms: A outcome comparison study

Objective To compare the safety and efficiency of stent assisted coiling (SAC) with non-SAC for the management of ruptured intracranial aneurysms. Methods A total of 1 217 patients with ruptured intracranial aneurysms who underwent endovascular treatment at Neurointervention Department of the First Affiliated Hospital of Zhengzhou University from January 2011 to January 2018 were retrospectively enrolled. Patients were categorized into SAC (n=631) and non-SAC (n=586) groups. We retrospectively analyzed the immediate postoperative occlusion degree and that at follow-up (based on Raymond scale) as well as perioperative complication rate in the two groups. The difference was considered as significant with P<0.05. Results In SAC group, the Raymond grades were grade Ⅰ in 65.0% (n=410), grade II in 29.9% (n=189) and grade Ⅲ in 5.0% (n=32), while those in non-SAC group were grade Ⅰ in 51.4% (n=301), grade Ⅱ in 36.0% (n=211) and grade Ⅲ in 12.6% (n=74), and the inter-group difference was significant (P 0.05). At 12 months post operation, DSA was performed in 227 cases of SAC group and 102 cases of non-SAC group. In SAC group, the Raymond grades were grade Ⅰ in 71.8% (n=163), grade Ⅱ in 22.9% (n=52) and grade Ⅲ in 5.3% (n=12), while those in non-SAC group were grade Ⅰ in 53.9 % (n=55), grade Ⅱ in 34.3% (n=35) and grade Ⅲ in 11.8% (n=12). The recurrence rate was 11.9% (n=27) in SAC group and 38.2% (n=39) in non-SAC group. Those inter-group differences were significant (P<0.01). Conclusions Compared with non-SAC, SAC is associated with higher occlusion rate, lower recurrence rate, lower rebleeding rate and relatively higher rate of ischemic event. However, mortality and disability rate between two groups do not seem to differ. Key words: Aneurysm, ruptured; Embolization, therapeutic; Stents; Treatment outcome; Coils

Appropriateness of immediate postoperative radiographs after open reduction and internal fixation of simple maxillofacial fractures––a retrospective audit

Aim: Immediate postoperative radiographs are routinely advised by surgeons for treatment of maxillofacial fractures. It is mainly for evaluation of the reduced fracture, alignment of plates, and assessment of occlusion. To scrutinize the requirement of routine postoperative radiography in patients treated by open reduction and internal fixation of fracture. Materials and Methods: The study was conducted retrospectively and radiographs of the patients who had reported to emergency department of our institute because of maxillofacial trauma from 2014 to 2016 were retrieved from the archive of dental radiology department. A total of 147 subjects were treated for 203 simple maxillofacial fractures. Information on age, gender, type of fracture, site of fracture, treatment carried out, and cause of retreatment if any were recorded. The continuous variables (age and number of fractures) were compared using the Mann– Whitney U test, whereas the Fisher’s exact test was used to compare categorical variables (gender and type of management). Results: The number of subjects that required re-treatment surgeries was evaluated. Only 13 subjects required re-treatment surgeries. Only in one subject (0.49%), the decision for re-treatment was based exclusively on postoperative radiographs. Six studies from the literature reported that postoperative occlusion can better predict the clinical outcome instead of immediate postoperative radiograph. The results of this study are in accordance with the literature review. Conclusion: Routine immediate postoperative radiograph may not be essential after management of simple maxillofacial fractures. Immediate postoperative radiographs may be indicated for subjects with possibility of complications.

Analysis between Retromandibular and Periangular Transmasseteric Approach for Fixation of Condylar Fracture - A Prospective Study.

Introduction:Condylar fractures make up for an average of 17.5%–52% of all mandibular fractures. The aim of the present study was to compare the ease, success, and complications between retromandibular and periangular transmasseteric approaches when used for open reduction and internal fixation of condylar fractures.Materials and Methods:A total 20 cases with condylar fracture, ten each for retromandibular and periangular transmasseteric approach, were included in the study. Patients were evaluated at 1 week, 1 month, 3 months, and 6 months. Postoperative occlusion, maximum mouth opening, range of movement, facial nerve function, visibility, convenience of plating, and time taken for exposure, fixation, and closure were recorded. Incidence of complications such as wound dehiscence, wound infection, hematoma, sialocele formation, Frey's syndrome, and hypertrophic scars were also evaluated.Results:The mean exposure time in the retromandibular approach was 10 min 31 s and 9 min 17 s in the periangular transmasseteric approach. The incidence of facial nerve injury was 2 of 10 patients in the retromandibular group and 3 of 10 patients in the periangular transmasseteric group, all of which resolved within 6 months. The incidence of sialocoele was 2 of 10 in the retromandibular group. The time taken for exposure of the fracture site was statistically significant between the two approaches (P = 0.048) with longer time required for retromandibular approach.Discussion:It can be summarized that both the approaches are comparable and well suited for surgical management of condylar fractures. It was observed that in displaced condylar neck fractures, greater difficulty was experienced in the periangular transmasseteric approach than the retromandibular approach.

The Influence of the Type of Surgery on the Immediate Postoperative Results in Patients with Colorectal Cancer Operated in Emergency.

The emergency surgery for colorectal cancer is associated with high rates of morbidity and mortality due to factors related to the characteristics of the patients but also the therapeutic attitude. This study aims to identify the surgical interventions associated with the postoperative complications, with the main causes of morbidity, with the reinterventions and with the postoperative deaths. We included in this retrospective study 431 patients hospitalized and operated in an emergency for complicated colorectal malignant tumors in the Surgery II Clinic of the Clinical Emergency County Hospital "Sf. Ap. Andrei from Galati, in the period 2008-2017. The patients data were collected from observation sheets, operative protocols, pathological, imaging and laboratory bulletins, at the time of the emergency intervention, as well as from those of subsequent admissions in patients who benefited from serial interventions. The postoperative morbidity was 10.44%. The resections with anastomosis were associated with the presence of postoperative complications (p 0.01): pseudomembranous colitis, (p 0.01) and postoperative intestinal occlusion (p 0.01). The practice of lymph node dissection was associated with postoperative complications (p 0.01): pseudomembranous colitis (p 0.01) and intestinal occlusion (p 0.01). The reinterventions were associated with resections with anastomosis (p 0.01), lymph node dissection (p 0.01) or patients with open /semi-open abdomen (p 0.04). The postoperative mortality was 9.28%. It was associated with the practice of lymph node dissection (p 0.01), of the ileostomy (p 0.01), with the open /semi-open abdomen (p 0.04). Patients with colostomy had the lowest number of hospitalization days (p 0.01). The resections with anastomosis per primam and the lymph node dissection were associated with morbidity. The type of main surgery did not influence the postoperative mortality, this being associated with the concomitant surgery: the lymph node dissection, the ileostomy, and the abdomen closure type. The reinterventions were associated with resections with anastomosis per primam, with lymph node dissection and with the open /semi-open abdomen. The duration of hospitalization was significantly shorter in patients with a colostomy.

Comparative study of outcomes between locking plates and three-dimensional plates in mandibular fractures.

Objectives:The objective was to compare the efficiency and assess postoperative complications of 2.00 mm unicortical locking plates and three-dimensional (3D) plates in surgical correction of uncomplicated mandibular fracture.Materials and Methods:A prospective cohort study of twenty patients of uncomplicated mandibular fractures, who were operated either by noncompression unicortical 2-mm locking mini-plate or by noncompression unicortical 2-mm 3D mini-plate, were enrolled and followed up for the study outcomes such as operative time, postoperative infection, and postoperative occlusion.Results:Majority of the patients (90%) were male who had road traffic accident. In 80% of cases, mandibular fracture site was parasymphysis. The mean operating time for 3D plates (43.20 min) was significantly lower than that for locking plates (54.82 min), P < 0.001. All cases operated by 3D plates compared to 60% by locking mini-plates did not need intermaxillary fixation, P = 0.025. The 80% of cases operated by 3D plates did not require postoperative occlusion correction compared to 30% in another group, P = 0.01. For other parameters such as postoperative sensory disturbance, postoperative infection, incidence tooth damage, vertical displacement of mandible, feeling of plate after platting, and chewing efficiency after 1 week, there were no statistical significant differences between the two groups.Conclusions:The outcome of 2.0mm 3D mini-plate is better in terms of operating time required, post-operative need of intermaxillary fixation and occlusal correction. While the outcome is similar to the use of non-compression unicortical 2.00mm locking miniplate in parameters like infection rate and incidence of tooth damage etc.

Conventional Versus 3D Plates for Mandibular Anterior Region Fractures: A Comparative Study

Introduction The management of facial trauma is one of the most challenging aspects for maxillofacial surgeons. The prominent position and configuration of the mandible make it one of the most frequent facial bones to be fractured. Open reduction and internal fixation are the preferred treatment methods for mandibular fractures. Objective To compare the effect of three-dimensional (3D) plates and conventional miniplates for internal fixation of anterior mandibular fractures. Material and Method This was a controlled and randomized clinical trial. A total of 14 patients aged between 21 and 50 years, who had symphyseal or parasymphyseal mandibular fractures, were randomly selected for this study from the outpatient clinic of the Oral and Maxillofacial Surgery Department. In this study, open reduction and internal fixation were performed for mandibular symphyseal and parasymphyseal region fractures using 3D plates in 7 patients as the study group and miniplates in 7 patients as the control group. Patients were followed for a period of 3 months at the interval of 1 week, 2 weeks, 4 weeks, 8 weeks, and 3 months for wound dehiscence, infection segmental mobility, postoperative occlusion, significant postoperative complications, and radiological evaluation of reduction, and fixation was done with a postoperative orthopantamogram (OPG) and 6 months postop computed tomography scan. Result There was no statistical difference between the 2 groups regarding pain, sensory response, operating time, occlusion, postoperative infection, wound dehiscence, mobility of fracture segment, and bone healing.

Complete Neck Vessels Preservation During Tevar Using Fenestrated Stent Graft for the Treatment of Saccular and Dissecting Arch Aneurysms

Introduction: Coverage of the left carotid artery or the left subclavian artery (LSA) with branch vessel bypass allows for increased utilization of thoracic endovascular aortic repair (TEVAR) in patients with a short proximal landing zone. TEVAR using fenestrated stent graft in the aortic arch could achieve a better sealing zone while preserving branch flow. We report the early and mid-term results of complete neck vessels preservation during TEVAR using the Najuta fenestrated stent graft for saccular and dissecting arch aneurysm, and describe its clinical usefulness and limitations. Methods: From April 2015 to March 2019, 146 TEVARs, including 50 Najuta fenestrated TEVARs were performed in our facility. We retrospectively analyzed 17 patients treated with complete neck vessels preservation using the Najuta stent graft for saccular and dissecting arch aneurysms. Fusiform aneurysms were excluded from this analysis. Results: Patients were predominantly male (76%), with a mean age of 73 years. Thoracic aortic aneurysms were saccular in 8 cases and dissecting in 9. Mean operative time was 137 minutes. The stent graft was landed in zone 0 in 8 cases, in zone 1 in 3 cases, and in zone 2 in 6 cases. Technical success was 100% with no 30-day mortality and no major aortic event. Mean length of proximal neck were 19.7mm in saccular aneurysm, 21mm in dissecting aneurysm. Postoperative LSA occlusion was encountered in one patient (5.9%) which was treated conservatively because it was asymptomatic. Type 1 endoleak was found in one patient (5.9%). No stroke, paraplegia and retrograde aortic dissection were encountered. During a median follow up of 8 months, no conversion to open surgical repair and no aortic rupture occurred. Conclusion: Although careful case selection is necessary, complete neck vessels preservation during TEVAR using the Najuta fenestrated stent graft appears to be a safe and effective treatment. This strategy also decreases need for branch vessel bypass. [Preoperative CT] [Postoperative CT] Disclosure: Nothing to disclose

Early postmarket results with PulseRider for treatment of wide-necked intracranial aneurysms: a multicenter experience.

Traditionally, stent-assisted coiling and balloon remodeling have been the primary endovascular treatments for wide-necked intracranial aneurysms with complex morphologies. PulseRider is an aneurysm neck reconstruction device that provides parent vessel protection for aneurysm coiling. The objective of this study was to report early postmarket results with the PulseRider device. This study was a prospective registry of patients treated with PulseRider at 13 American neurointerventional centers following FDA approval of this device. Data collected included clinical presentation, aneurysm characteristics, treatment details, and perioperative events. Follow-up data included degree of aneurysm occlusion and delayed (> 30 days after the procedure) complications. A total of 54 aneurysms were treated, with the same number of PulseRider devices, across 13 centers. Fourteen cases were in off-label locations (7 anterior communicating artery, 6 middle cerebral artery, and 1 A1 segment anterior cerebral artery aneurysms). The average dome/neck ratio was 1.2. Technical success was achieved in 52 cases (96.2%). Major complications included the following: 3 procedure-related posterior cerebral artery strokes, a device-related intraoperative aneurysm rupture, and a delayed device thrombosis. Immediately postoperative Raymond-Roy occlusion classification (RROC) class 1 was achieved in 21 cases (40.3%), class 2 in 15 (28.8%), and class 3 in 16 cases (30.7%). Additional devices were used in 3 aneurysms. For those patients with 3- or 6-month angiographic follow-up (28 patients), 18 aneurysms (64.2%) were RROC class 1 and 8 (28.5%) were RROC class 2. PulseRider is being used in both on- and off-label cases following FDA approval. The clinical and radiographic outcomes are comparable in real-world experience to the outcomes observed in earlier studies. Further experience is needed with the device to determine its role in the neurointerventionalist's armamentarium, especially with regard to its off-label use.

Tailored cell sheet engineering using microstereolithography and electrochemical cell transfer

Postoperative adhesion and occlusion remain a serious issue associated with various surgeries, including endoscopic surgery, in which proliferated fibrous tissues stick to adjacent tissues and often cause severe complications. Cell sheet engineering has emerged as an effective approach not only for cell transplantation but also for the treatment of postoperative adhesion and occlusion. However, as the tissues in the body, such as middle ear and small intestine, and typical operative sites are non-flat and spatially complicated, tailored cell sheets with three-dimensional (3D) configurations may lead to widespread use of this approach. In the present study, we used microstereolithography, biocompatible gold plating, and electrochemical cell detachment to achieve this purpose. Various objects with dimensions ranging from millimeter- to micrometer-scale were fabricated with photocurable resin using lab-made equipment for microstereolithography. To coat the fabricated objects with a thin gold layer, conventional cyanide-based gold plating was unusable because it severely damaged almost all cells. Electroless non-cyanide gold plating we prepared was cytocompatible and suitable for electrochemical cell detachment. Cell sheets on the gold-plated substrate could be directly transplanted into a mouse intraperitoneally using electrochemical cell detachment. We further demonstrated that cell sheets grown on gold-coated 3D objects were rapidly detached along with the desorption of electroactive-oligopeptide monolayer and transferred to a surrounding hydrogel. This approach may provide a promising strategy to prepare and directly transplant tailor-made cell sheets with suitable configurations.

Locking Versus Non-Locking Plate Fixation in the Management of Maxillofacial Fractures : A Prospective Comparative Study

Introduction Various methods of fixation have been advocated for the treatment of maxillofacial fractures. A new type of plating system, initially developed by Raveh et al. is locking plate/screw system. This system has various advantages over conventional non locking plating system like better stability, ease of plate adaptation, early restoration of function, internal locking system which decreases the chance of screw loosening and infection. Objectives A comparative evaluation of locking plates system versus conventional miniplates in maxillofacial fractures. Method Twenty patients presenting with maxillofacial fractures were treated with locking plates and conventional non locking plates in two years from 2014 to 2016. Ten patients were treated with locking plate system in group A and 10 patients with conventional non locking plates in group B. Patients were evaluated on clinical and radiographic parameters during three months follow up. Results Postoperative outcomes for both groups were extremely favorable with a relatively small number of complications. There was no case of postoperative wound dehiscence, infection, damage to tooth roots, plate exposure and plate removal, malunion and any other complication in both the groups. Postoperative occlusion disturbance was seen in 20% cases in both group A as well as group B in mandible fractures. In maxillary fractures postoperative occlusion disturbance was seen in one case (20%) in group B. Conclusion This study concluded that despite the significant theoretical advantages of locking system seen in biomechanical studies, no statistical significant results were found between these two systems. The postoperative outcomes for both groups were almost similar with a relatively small number of complications.

Surgical Outcomes and Their Correlation with Increasing Surgical Experience in a Series of 250 Ruptured or Unruptured Aneurysms Undergoing Microsurgical Clipping

The development of endovascular techniques has offered extraordinary therapeutic opportunities to treat intracranial aneurysms. However, mainly for anterior circulation aneurysms, no clear superiority of these techniques compared with microsurgical clipping has been shown in terms of morbidity, mortality, aneurysm occlusion rate, and long-term protection from recanalization and rebleeding. We reviewed the data from a retrospective case series to determine the clinical and radiological outcomes of clipped ruptured and unruptured aneurysm to analyze the relationship between increasing surgical experience and operative time, recovery time, and clinical outcomes. A total of 250 consecutive aneurysms in 221 patients had been treated from June 2009 to June 2015. The postoperative complications, recovery time (only for the unruptured group), operative time, clinical outcomes, and aneurysm occlusion rate at 3 months were analyzed for both ruptured and unruptured aneurysms. Linear regression was used to analyze the relationship between surgical experience and the operative time, recovery time, and clinical outcomes. The complication rate was very low in the unruptured cases (117 patients), with 100% of patients in good clinical status at 3 months. In the ruptured cases (104 patients), the presenting neurological status significantly influenced the postoperative outcomes. Complete obliteration found on the 3-month digital subtraction angiogram was obtained for 96.6% of the treated aneurysms in both groups. A significant correlation was found between surgical experience and both the operative time and recovery time. In a subset of patients (aneurysm located in the anterior circulation and <12 mm), microsurgical clipping appeared to be as safe as endovascular treatment and can obtain a very high complete occlusion rate. Increasing surgical experience improved the operative time and recovery time, with a trend toward improvement of the clinical outcomes.

Simulation of postoperative occlusion and direction in autotransplantation of teeth: application of computer-aided design and digital surgical templates

Autotransplantation of teeth requires optimisation of both occlusion and direction to ensure minimal injury to the dental crown and the alveolar bone. We describe a method that could simulate postoperative occlusion and direction of the donor tooth by using CAD and digital surgical templates, and evaluate the postoperative effect in five patients who had teeth autotransplanted. Computed tomographic data were imported into ProPlan CMF 3.0 software, the donor tooth was simulated to replace the recipient site according to the position of the occlusion and alveolar bone, and a digital template was designed to guide preparation of the socket. A computer-aided, rapid prototyped, tooth was used to match the socket and, finally, an occlusal template was designed to ensure that the donor tooth was in the simulated position. We compared the position of the tooth in the simulation with its postoperative position using ProPlan CMF 3.0 software. In this way it was possible to simulate and guide the donor tooth accurately to the recipient site. At six-month follow up all teeth had survived successfully. Given the efficiency and precision of placement and the success, we conclude that CAD can successfully help to simulate occlusion and direction in autotransplantation of teeth while simplifying the procedure.

A prospective comparative clinical study on modified screw retained arch bar (SRAB) and conventional Erich's arch bar (CEAB).

Intermaxillary fixation (IMF) is commonly performed in the management of facial skeleton fractures. Various conventional methods like Erich's arch bar and Ivy eyelet wiring are the most commonly employed methods for achieving IMF, but they have their own disadvantages. Conventional Erich's arch bar (CEAB) has been modified recently by making perforations in the spaces between the winglets and securing the arch bar using 1mm screws. IMF using intraoral modified screw retained arch bar (SRAB) has been introduced for the treatment of mandibular fractures. The aim of this study was to compare the efficacy, advantages, disadvantages, indications, and potential complications associated with CEAB versus modified SRAB in the management of mandibular fractures. A randomized prospective study included 20 patients with mandibular fracture who were randomly allotted to two groups. Group A patients received modified SRAB and group B patients received CEAB. The parameters considered were time taken to place the arch bar, perforation in the gloves, patient acceptance, oral hygiene, iatrogenic dental injuries, and needle (wire) stick injuries during IMF. The mean time taken for arch bar placement was 27.20min with modified SRAB as compared with 82.50min with CEAB. Incidence of glove perforations was more in group B patients. Oral hygiene status was good in 90% of the patients from group A whereas it was 100% fair in group B patients. This study has shown that both the techniques achieve satisfactory IMF with post-operative occlusion. IMF with modified SRAB reduces the operating time and the incidence of the needle (wire) prick injuries. But modified SRAB has its own limitations in spite of its ease of application.

A Modified Novel Technique for Condylar Positioning in Mandibular Bilateral Sagittal Split Osteotomy Using Computer-Assisted Designed and Computer-Assisted Manufactured Surgical Guides

Current techniques for orthognathic surgery after Le Fort I osteotomy and bilateral sagittal split osteotomy (BSSO) rely on intermediate and final occlusal splints for proper positioning of the dental arches without any control in positioning the condyle and ramus segments. Setting the 2 condyles in centric relation in the glenoid fossae at fixation is paramount for condylar function and the accuracy and stability of postoperative occlusion. Usually the 2 ramus segments are manually positioned and fixated in the final position according to the surgeon's experience. This report describes a novel technique to position the condyle and ramus segments in centric relation using skeletal guides designed by computer-assisted designed and computer-assisted manufactured (CAD-CAM) technology. The skeletal guides have a double-U shape designed to be tooth borne on the distal segment and bone borne on the proximal segment. The guides fit on the last molar crown and the anterior border of the ramus; using these reference points will position the mandibular arch and 2 ramus segments in ideal centric occlusion and centric relation. The condyle position in the sagittal, horizontal, and transverse planes was analyzed by computed tomography and differences in measurements were calculated. This technique confirms precise control of the condylar segment in centric relation with stable centric occlusion using CAD-CAM guides during BSSO.

Experimental Studies for Small Diameter Grafts in an In Vivo Sheep Model-Techniques and Pitfalls.

Scientific attempts to create the "ideal" small diameter vascular graft have been compared with the "search of the holy grail." Prosthetic material as expanded polytetrafluoroethylene or Dacron shows acceptable patency rates to large caliber vessels, while small diameter (< 6 mm) prosthetic conduits present unacceptably poor patency rates. Vascular tissue engineering represents a promising option to address this problem. Thirty-two female Texel-sheep aged 6 months to 2 years underwent surgical common carotid artery (CCA) interposition using different tissue-engineered vascular substitutes. Explantation of the grafts was performed 12 (n = 12) and 36 (n = 20) weeks after surgery. Ultrasound was performed on postoperative day 1 and thereafter every 4 weeks to evaluate the graft patency. The average length of implanted substitutes was 10.3 ± 2.2 cm. Anesthesia and surgical procedure could be performed without major surgical complications in all cases.The grafts showed a systolic blood flow velocity (BFV) of 28.24 ± 13.5 cm/s, a diastolic BFV of 9.25 ± 4.53 cm/s, and a mean BFV of 17.85 ± 9.25 cm/s. Native vessels did not differ relevantly in hemodynamic measurements (systolic: 29.77 cm/s; diastolic: 7.99 cm/s ± 5.35; mean 15.87 ± 10.75). There was no incidence of neurologic complications or subsequent postoperative occlusion. Perioperative morbidity was low and implantation of conduits was generally well tolerated. This article aims to give a precise overview of in vivo experiments in sheep for the evaluation of small diameter vascular grafts performing CCA interposition, especially with regard to pitfalls and possible perioperative complications and to discuss advantages and disadvantages of this approach.

Jotec E-Ventus BX Stent Graft Deployment in the FEVAR and Iliac Branch Device: Single Centre Experience.

Objectives: To evaluate the outcomes of the E-ventus BX balloon-expandable stent graft system (Jotec, Hechingen, Germany) implanted as bridging stent grafts during fenestrated endovascular aortic repair (FEVAR) and the iliac branch device (IBD) of complex aneurysms.Methods: This was a single centre retrospective analysis prospective study including all consecutive patients treated by FEVAR and the IBD performed with E-ventus BX stent grafts as bridging stents. Demographics of patients, the diameter and length of the bridging stent grafts, technical success, reinterventions, occlusions, post-operative events, and imaging (computed tomography [CT] scan and ultrasound) were prospectively collected in an electronic database. Follow-ups were performed with clinical assessment and a CT angiogram scan at four weeks after discharge followed by a duplex ultrasound every six months for two years and then a yearly duplex scan afterwards.Results: Between June 2015 and October 2017, 40 consecutive patients (three females) were treated with custom made fenestrated endografts and the iliac branch device for complex aneurysms, using the E-Ventus BX stent graft. All 82 E-Ventus BX stent grafts were successfully delivered and deployed. There was no in-hospital mortality. The early bridging stents patency rate was 97.6% (80 out of 82). The two-target vessel post-operative occlusion was secondary to kink of the renal stents and failure for re-lining of the renal artery. Of the two patients, only one needed permanent dialysis. On the late follow-up (after 30 days), two other patients demonstrated a renal stent occlusion, with one treated successfully with re-lining of the stent and the other patient treated conservatively. Neither of them needed permanent dialysis. A follow-up was maintained for 36 patients until April 2018 with a median follow-up of 18 months. All bridging stents E-Ventus BX stent grafts remained patent (78 out of 82, 95.1%).Conclusion: E-Ventus BX stent grafts used as bridging stents during FEVAR and the IBD are associated with favourable outcomes at the mid-term follow-up. Long-term follow-up is required to confirm these promising results.

Role of botulinum neurotoxin-A in cerebral revascularization graft vasospasm prevention: current state of knowledge.

Graft stenosis and occlusion remain formidable complications in cerebral revascularization procedures, which can lead to significant morbidity and mortality. Graft vasospasm can result in early postoperative graft stenosis and occlusion and is believed to be at least partially mediated through adrenergic pathways. Despite various published treatment protocols, there is no single effective spasmolytic agent. Multiple factors, including anatomical and physiological variability in revascularization conduits, patient age, and comorbidities, have been associated with graft vasospasm pathogenesis and response to spasmolytics. The ideal spasmolytic agent thus likely needs to target multiple pathways to exert a generalizable therapeutic effect. Botulinum toxin (BTX)-A is a powerful neurotoxin widely used in clinical practice for the treatment of a variety of spastic conditions. Although its commonly described paradigm of cholinergic neural transmission blockade has been widely accepted, evidence for other mechanisms of action including inhibition of adrenergic transmission have been described in animal studies. Recently, the first pilot study demonstrating clinical use of BTX-A for cerebral revascularization graft spasm prevention has been reported. In this review, the mechanistic basis and potential future clinical role of BTX-A in graft vasospasm prevention is discussed.

Peritoneal closure using self-anchoring-barbed absorbable sutures during laparoscopic transabdominal preperitoneal inguinal hernioplasty: How to make it more safe?

CONTEXT: Peritoneal closure with a barbed suture during laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair is a controversial subject due to the risk of postoperative intestinal adhesions and occlusions formed by this type of suture. This risk, however, was only reported in several case reports. The purpose of this study is to determine the incidence of postoperative intestinal obstructions related to the use of barbed suture materials in laparoscopic hernia repair (TAPP). PATIENTS AND METHODS: We included all patients that underwent laparoscopic TAPP inguinal hernia repair between October 2012 and October 2017. All peritoneal closures were accomplished using absorbable barbed sutures. Operative data were collected in a dedicated database and analyzed retrospectively. RESULTS: Only 3 out of the 320 patients included (0.9%) presented with an early postoperative intestinal obstruction and required further surgery. Two of the three patients (0.6%) were found to have intestinal incarceration in the peritoneal defects initially created during the hernia repair. However, the last patient had an intestinal volvulus due to adhesions formed with the barbed suture. None of the patient characteristics collected were significant risk factors for developing postoperative intestinal obstructions. CONCLUSION: In this study, peritoneal closure using barbed suture material did not increase the risk of early postoperative intestinal obstruction, in comparison to other suture materials reported in the literature. The use of barbed absorbable sutures for peritoneal closure during laparoscopic TAPP seems to be safe when sutures are cut short and covered by the peritoneum.