Proximal Graft Research Articles

40: Abdominal sacrocolpopexy with rectus fascia autograft

This video aims to show several novel techniques that can be utilized when performing an abdominal sacrocolpopexy as well as how a rectus fascia autograft free tissue transfer can be used for suspension of the vagina. We present a patient with recurrent stage III post-hysterectomy vaginal vault prolapse. She desired definitive surgical management and opted for a technique in which no mesh would be used. After creating a pfannensteil incision, a 10 cm x 1.5 cm portion of rectus fascia is harvested for the autograft. Once the intraperitoneal cavity is entered, attention is turned to the sacral promontory. An end-to-end anastomosis (EEA) sizer is placed in the vagina to replicate the desired surgical outcome. After incising the pre-sacral peritoneum, a Kittner is used to gently dissect the fat and expose the anterior longitudinal ligament (ALL). Two Gortex sutures are placed through the ALL at approximately S2 – S3. The Gortex sutures are then placed through the proximal graft fold. Utilizing a laparoscopic knot pusher, the Gortex sutures are easily secured deep within the pelvis. The vagina is then affixed to the autograft with 0-Ethibond sutures starting with the posterior aspect of the vaginal suspension so as not to obstruct surgeon visualization. At the conclusion of the case, the vagina is well suspended with resolution of prolapse on examination. Performing an open abdominal sacrocolpopexy using rectus fascia autograft free tissue transfer, as demonstrated in our video, allows for excellent anatomic outcomes and avoids the concerns posed by implantation of mesh.

Inhibiting intimal hyperplasia in prosthetic vascular grafts via immobilized all-trans retinoic acid

Peripheral arterial disease is a leading cause of morbidity and mortality. The most commonly utilized prosthetic material for peripheral bypass grafting is expanded polytetrafluoroethylene (ePTFE) yet it continues to exhibit poor performance from restenosis due to neointimal hyperplasia, especially in femoral distal bypass procedures. Recently, we demonstrated that periadventitial delivery of all-trans retinoic acid (atRA) immobilized throughout porous poly(1,8 octamethylene citrate) (POC) membranes inhibited neointimal formation in a rat arterial injury model. Thus, the objective of this study was to investigate whether atRA immobilized throughout the lumen of ePTFE vascular grafts would inhibit intimal formation following arterial bypass grafting. Utilizing standard ePTFE, two types of atRA-containing ePTFE vascular grafts were fabricated and evaluated: grafts whereby all-trans retinoic acid was directly immobilized on ePTFE (atRA-ePTFE) and grafts where all-trans retinoic acid was immobilized onto ePTFE grafts coated with POC (atRA-POC-ePTFE). All grafts were characterized by SEM, HPLC, and FTIR and physical characteristics were evaluated in vitro. Modification of these grafts, did not significantly alter their physical characteristics or biocompatibility, and resulted in inhibition of intimal formation in a rat aortic bypass model, with atRA-POC-ePTFE inhibiting intimal formation at both the proximal and distal graft sections. In addition, treatment with atRA-POC-ePTFE resulted in increased graft endothelialization and decreased inflammation when compared to the other treatment groups. This work further confirms the biocompatibility and efficacy of locally delivered atRA to inhibit intimal formation in a bypass setting. Thus, atRA-POC-ePTFE grafts have the potential to improve patency rates in small diameter bypass grafts and warrant further investigation.

A Case of Total Arch Replacement for Non-anastomotic Pseudoaneurysm by Proximal Stent Graft Induced-Vascular Graft Perforation in Loeys-Dietz Syndrome after Total Aortic Replacement

A Case of Total Arch Replacement for Non-anastomotic Pseudoaneurysm by Proximal Stent Graft Induced-Vascular Graft Perforation in Loeys-Dietz Syndrome after Total Aortic Replacement

Efficacy of serosomyotomy in esophagogastroplasty

To evaluate an effectiveness of serosomyotomy in isoperistaltic esophagogastroplasty. Our analysis shows that serosomyotomy improves the results of isoperistaltic esophagogastroplasty. Esophagogastrostomy by using of proximal graft with adequate blood supply reduced the risk of anastomosis failure. The incidence of this complication was 12.2% (n=6) and 3% (n=1) in control and main groups respectively.

Feasibility Study of a Novel Thoraco-abdominal Aortic Hybrid Device (SPIDER-graft) in a Translational Pig Model

The hybrid SPIDER-graft consists of a proximal descending aortic stent graft and a conventional six branched Dacron graft for open abdominal aortic repair. Technical feasibility with regard to avoiding thoracotomy and extracorporeal circulation (ECC) during thoraco-abdominal aortic hybrid repair and peri-procedural safety of this novel device are unknown. This was a feasibility and safety study in domestic pigs (75-85kg). The abdominal aorta including iliac bifurcation, left renal artery, and visceral arteries were exposed via retroperitoneal access. The right iliac branch was first temporarily anastomosed end to side to the distal aorta via partial clamping. During inflow reduction and infra-coeliac cross-clamping, the coeliac trunk (CT) was divided and the proximal stent graft portion of the SPIDER-graft was deployed into the descending aorta via the CT ostium. Retrograde visceral and antegrade aorto-iliac blood flow was maintained via the iliac side branch. The visceral, renal, and iliac arteries were sequentially anastomosed, finally replacing the first iliac end to side anastomosis. Technical success, blood flow, periods of ischaemia, and peri-procedural complications were evaluated after intra-operative completion angiography and post-operative computed tomography angiography. Six animals underwent successful thoracic stent graft deployment and distal open reconstruction without peri-operative death. The median thoracic graft implantation time was 4.5min, and the median ischaemia times before reperfusion were 10min for the CT, 8min for the superior mesenteric artery, 13min for the right renal artery, and 22min for the left renal artery. Angiography demonstrated appropriate graft implantation and blood flow measurements confirmed sufficient blood flow through all side branches. In this translational pig model, thoraco-abdominal hybrid repair using the novel SPIDER-graft was successful in avoiding thoracotomy and ECC. Technical feasibility and safety appear promising, but need to be reassessed in humans.

Impact of proximal radiopaque coronary bypass graft markers on postbypass surgery coronary angiography

BackgroundImplantation of radiopaque bypass graft markers during coronary artery bypass surgery (CABG) has the potential of facilitating subsequent coronary angiography. This study sought to investigate the impact of proximal coronary bypass graft markers on angiographic outcomes during subsequent coronary angiography in a large cohort. Methods and ResultsBetween 2005 and 2016, we enrolled 1378 patients (331 with and 1047 without bypass graft markers) with a history of CABG who underwent their first subsequent coronary angiography at our institution. Primary endpoints were radiation time and absolute amount of contrast media used. In unadjusted analyses, radiation time, duration of angiography, dose area product, and the amount of contrast agent were significantly lower in patients with proximal bypass graft markers (P < .001). After full adjustment, proximal coronary bypass graft markers remained a significant predictor for less radiation time and a lower consumption of contrast agent but not for dose area product, which was mainly associated with body mass index and sex. Bypass graft markers were not associated with a lower graft patency. ConclusionsRadiopaque coronary bypass graft markers can improve the detection of bypass grafts during subsequent coronary angiography and are associated with a lower radiation time and less consumption of contrast agent. Thus, this easy and cost-efficient technique might significantly reduce the risk of coronary angiography after CABG.

Changes in aortic pulse wave velocity of four thoracic aortic stent grafts in an ex vivo porcine model.

ObjectivesThoracic endovascular aortic repair (TEVAR) has been shown to lead to increased aortic stiffness. The aim of this study was to investigate the effect of stent graft type and stent graft length on aortic stiffness in a controlled, experimental setting.MethodsTwenty porcine thoracic aortas were connected to a pulsatile mock loop system. Intraluminal pressure was recorded at two sites in order to measure pulse wave velocity (PWV) for each aorta: before stent graft deployment (t1); after deployment of a 100-mm long stent graft (t2); and after distal extension through deployment of a second 100-mm long stent graft (t3). Four different types of stent grafts (Conformable Gore® TAG® Device, Bolton Relay® Device, Cook Zenith Alpha™, and Medtronic Valiant®) were evaluated.ResultsFor the total cohort of 20 aortas, PWV increased by a mean 0.6 m/s or 8.9% of baseline PWV after deployment of a 100-mm proximal stent graft (P<0.001), and by a mean 1.4 m/s or 23.0% of baseline PWV after distal extension of the stent graft (P<0.001). Univariable regression analysis showed a significant correlation between aortic PWV and extent of stent graft coverage, (P<0.001), but no significant effect of baseline aortic length, baseline aortic PWV, or stent graft type on the percentual increase in PWV at t2 or at t3.ConclusionsIn this experimental set-up, aortic stiffness increased significantly after stent graft deployment with each of the four types of stent graft, with the increase in aortic stiffness depending on the extent of stent graft coverage.

Late Complication after Thoracic Endovascular Aortic Repair: What Is the Role of an Open Surgical Conversion?

The aim was to evaluate the causes of thoracic endovascular aortic repair (TEVAR) failure and conversion to open surgery (COS) in a vascular center with high-volume open surgery and low-volume TEVAR procedures. A total of 8 patients (6 men; mean age, 55.14years) underwent COS after TEVAR. The indications for COS, intraoperative strategy, and early postoperative and mid-follow-up results were analyzed. The indications for COS were persistent proximal type I endoleak with progressive aneurysm enlargement in 2 patients, type III endoleak in 1 patient, progressive aneurysm enlargement with no endoleak in 1 patient, stent-graft migration in 2 patients, secondary aortoesophageal fistula in 1 patient, secondary aortoesophageal and aortobronchial fistula in 1 patient, and distal progression of the aneurysmal disease in 2 patients. In all but one patient, thoracic stent grafts were explanted, and replacement with a Dacron graft was performed using left partial cardiopulmonary bypass. In the remaining patients with disconnection of the distal component and unfavorable anatomy, the proximal stent graft was recycled, and the Dacron prosthesis was sewn to it. Patients with secondary aortobronchial and aortoesophageal fistulas required additional bronchial and esophageal repair. The in-hospital mortality rate was 50% (4 patients). Four (50%) patients were followed up between 7 and 24months (mean, 16.75months) without mortality. COS after TEVAR has a high mortality rate, and endovascular techniques should be considered as the first line of treatment. Those procedures should be performed by surgeons experienced in open repair which one might expect to be a challenging problem in the era of endovascular therapy.

An Assessment of Renal Function with Pulsatile Perfusion During Proximal Graft Using Cardiac Contraction in Coronary Artery Bypass Graft Surgery

Background: Short-term pulsatile perfusion during cardio pulmonary bypass has shown higher protection for renal physiology, following standard preservation of glomerular filtration and reduction of renal tissue damage. Methods: In this randomized clinical trial study, 70 patients, who had undergone CABG surgery were divided to 2 groups; pulsatile and non-pulsatile groups. The researchers transferred continuous blood flow to pulsatile blood flow during proximal graft using cardiac contraction. Patients’ laboratory tests, such as blood urea nitrogen (BUN) and creatinine were checked preoperatively, at the arrival of the open heart intensive care unit (ICU-OH), and 24 and 48 hours after admission. Results: Both case and control groups had significantly increased BUN and creatinine. Increased creatinine on the first and second postoperative day was significantly higher in the control group. Furthermore, BUN increased on the second day in the control group and was significantly higher than the case group Conclusions: Despite the rise in BUN and creatinine in the 2 groups, there were no cases of renal failure in the patients. However, the results of this study regarding creatinine and BUN criteria were supported by the pulsatile perfusion method during the proximal graft by using a cardiac contraction in CABG surgery.

Stent-graft balloon occlusion with selective cerebral perfusion for cardiac surgery after proximal aortic arch stent grafting: A case report

Stent-graft balloon occlusion with selective cerebral perfusion for cardiac surgery after proximal aortic arch stent grafting: A case report

WITHDRAWN: Evaluation of autogenous fibular reconstruction after enbloc excision of a giant cell tumor from the distal radius: Minimum two years follow up

Abstract Background A giant cell tumour is a benign neoplasm. The distal radius (10%) is the third most common site after distal femur and proximal tibia. It is usually associated with local aggressive behaviour and high recurrence rate. Multiple modalities are accepted for treatment of aggressive giant-cell tumour (GCT) of the distal radius. The purpose of our study was to investigate the autogenous fibular reconstruction after enbloc excision of a giant cell tumor from the distal radius. Method In this retrospective study ten cases of patients with GCT of the distal radius who have undergone en bloc resection and reconstruction with non-vascularised autologous proximal fibular graft of the ipsilateral side. Results The mean follow up duration in this study was 3.3 years. Eight patients (80%) achieved union while two patients had non-union. Two patients had non union for which iliac crest bone grafting was repeated at 9 and 12 months and graft ultimately united at 12 and 16 months respectively. One case got infection and there were two cases of wrist subluxation. Satisfactory range of movement was achieved in all patients. At last follow-up, the average combined range of motion was 101.5° Conclusion This procedure provides a valid treatment option in managing aggressive GCTs of the distal radius and provides good cosmetic and functional results.

Experimental Assessment of Physician Modified Proximal Scalloped Stent Graft to Extend Proximal Landing Zone in the Aortic Arch

The aim of the study was to assess a model of physician modified scalloped stent graft (PMSG) on currently available thoracic aortic devices to extend the proximal landing zone in either zone 2, 1 or 0 of the aortic arch while preserving flow in the supra-aortic vessels on human cadaveric aorta. Fresh human aortas were harvested at autopsy from adult subjects. A proximal scallop was made on the stent grafts based on direct measurements on the aortas to extend the proximal landing zone in zone 0 (n=5), zone 1 (n=5), and zone 2 (n=5). A previously described benchtop closed system pulsatile flow model was used to mimic flow and pressure conditions in the aorta to deploy the stent graft as close to physiological conditions as possible. Deployment accuracy of the scallop opposite the aortic arch branch ostia was assessed by completion angiography and post-procedural analysis of the aortas. Fifteen proximal scalloped stent grafts were deployed in the aortic arch of 15 human cadaveric aortas under fluoroscopy. The expected proximal landing zone was achieved in all cases (zone 2=5; zone 1=5; zone 0=5). Post-procedural angiography and direct visual analysis showed supra-aortic vessel patency and deployment of the scallop opposite the aortic arch branch ostia in all cases. PMSG to extend the proximal landing zone in zone 2, 1, or 0 in order to treat urgent diseases of the proximal descending aorta or the inner circumference of the aortic arch by a totally endovascular approach while preserving flow in the supra-aortic trunks is experimentally feasible.

IF15. Implantation of Proximal Thoracic Stent Graft and Distal Bare Stent Promotes True Lumen Expansion but Not Aortic Remodeling in Patients With Chronic Complicated Type B Aortic Dissection

IF15. Implantation of Proximal Thoracic Stent Graft and Distal Bare Stent Promotes True Lumen Expansion but Not Aortic Remodeling in Patients With Chronic Complicated Type B Aortic Dissection

Superior Lower Extremity Vein Graft Bypass Patency among Married Patients with Peripheral Artery Disease

Outcome disparities associated with lower extremity bypass (LEB) for peripheral artery disease (PAD) have been identified but are poorly understood. Marital status may affect outcomes through factors related to health risk behaviors, adherence, and access to care but has not been characterized as a predictor of surgical outcomes and is often omitted from administrative data sets. We evaluated associations between marital status and vein graft patency following LEB using multivariable models adjusting for established risk factors. Consecutive patients undergoing autogenous LEB for PAD were identified and analyzed. Survival analysis and Cox proportional hazards models were used to evaluate patency stratified by marital status (married versus single, divorced, or widow[er]) adjusting for demographic, comorbidity, and anatomic factors in multivariable models. Seventy-three participants who underwent 79 autogenous vein LEB had complete data and were analyzed. Forty-three patients (58.9%) were married, and 30 (41.1%) were unmarried. Compared with unmarried patients, married patients were older at the time of their bypass procedure (67.3±10.8years vs. 62.2±10.6years; P=0.05). Married patients also had a lower prevalence of female gender (11.6% vs. 33.3%; P=0.02). Diabetes, hypertension, hyperlipidemia, and smoking were common among both married and unmarried patients. Minimum great saphenous vein conduit diameters were larger in married versus unmarried patients (2.82±0.57mm vs. 2.52±0.65mm; P=0.04). Twenty-four-month primary patency was 66% for married versus 38% for unmarried patients. In a multivariable proportional hazards model adjusting for proximal and distal graft inflow/outflow, medications, gender, age, race, smoking, diabetes, and minimum vein graft diameter, married status was associated with superior primary patency (hazard ratio [HR] = 0.33; 95% confidence limits [0.11, 0.99]; P=0.05); other predictive covariates included preoperative antiplatelet therapy (HR=0.27; 95% confidence limits [0.10,0.74]; P=0.01) and diabetes (HR = 2.56; 95% confidence limits [0.93-7.04]; P=0.07). Marital status is associated with vein graft patency following LEB. Further investigation into the mechanistic explanation for improved patency among married patients may provide insight into social or behavioral factors influencing other disparities associated with LEB outcomes.

The Graft Bending Angle Can Affect Early Graft Healing After Anterior Cruciate Ligament Reconstruction: In Vivo Analysis With 2 Years’ Follow-up

Background: A high graft bending angle (GBA) after anterior cruciate ligament (ACL) reconstruction has been suggested to cause stress on the graft. Nevertheless, evidence about its effect on graft healing in vivo is limited. Hypothesis: The signal intensity on magnetic resonance imaging (MRI) would be higher in the proximal region of the ACL graft, and higher signals would be correlated to a higher GBA. Study Design: Descriptive laboratory study. Methods: Anatomic single-bundle ACL reconstruction was performed on 24 patients (mean age, 20 ± 4 years) using the transportal technique. A quadriceps tendon autograft with a bone plug was harvested. To evaluate graft healing, the signal/noise quotient (SNQ) was measured in 3 regions of interest (ROIs) of the proximal, midsubstance, and distal ACL graft using high-resolution MRI (0.45 × 0.45 × 0.70 mm), with decreased signals suggesting improved healing. Dynamic knee motion was examined during treadmill walking and running to assess the in vivo GBA. The GBA was calculated from the 3-dimensional angle between the graft and femoral tunnel vectors at each motion frame, based on tibiofemoral kinematics determined from dynamic stereo X-ray analysis. Graft healing and GBAs were assessed at 6 and 24 months postoperatively. Repeated-measures analysis of variance was used to compare the SNQ in the 3 ROIs at 2 time points. Pearson correlations were used to analyze the relationship between the SNQ and mean GBA during 0% to 15% of the gait cycle. Results: The SNQ of the ACL graft in the proximal region was significantly higher than in the midsubstance (P = .022) and distal regions (P < .001) at 6 months. The SNQ in the proximal region was highly correlated with the GBA during standing (R = 0.64, P < .001), walking (R = 0.65, P = .002), and running (R = 0.54, P = .015) but not in the other regions. At 24 months, signals in the proximal and midsubstance regions decreased significantly compared with 6 months (P < .001 and P = .008, respectively), with no difference across the graft area. Conclusion: The signal intensity was highest in the proximal region and lowest in the distal region of the reconstructed graft at 6 months postoperatively. A steep GBA was significantly correlated with high signal intensities of the proximal graft in this early period. A steep GBA may negatively affect proximal graft healing after ACL reconstruction.

Unilateral inline replacement of infected aortofemoral graft limb with femoral vein

ObjectiveAortic graft infection remains a formidable challenge for the vascular surgeon. Traditionally, reconstruction with a neoaortoiliac system (NAIS) involves removal of the entire synthetic graft with in situ reconstruction using femoral vein. Whereas the NAIS procedure is durable with excellent graft patency and a low reinfection rate, it can take up to 10 hours and result in a high perioperative complication rate with significant mortality. Not infrequently, the infection is limited to a single limb. In addition, the patient may be too frail to tolerate aortic clamping for a complete graft excision. Under such circumstances, complete excision of the aortofemoral bypass graft (AFBG) may not be indicated. It is hypothesized that local control of infection and limited reconstruction using femoral vein may be acceptable. The objective of this study was to examine the outcomes of all patients who underwent partial AFBG resection and in situ reconstruction with femoral vein. MethodsA retrospective review of all AFBG infections from 2003 to 2015 treated at a tertiary care facility was undertaken. Patients who underwent unilateral partial graft excision with inline reconstruction using femoral vein at the distal (femoral) anastomosis were included. Complete excisions with bilateral revascularizations using any conduit or any extra-anatomic reconstructions were excluded. The primary end point was successful treatment of infection. Secondary end points were procedure-related mortality, graft patency, and perioperative complications. ResultsDuring a 12-year period, partial graft excision with bypass using the femoral vein was performed in 21 patients (24 limbs). Mean age was 61 ± 12 years. There were 13 men and 8 women. Mean follow-up was 53 ± 27 months. Successful treatment was achieved in 19 of 21 patients. The two treatment failures were due to persistent infection. One of these patients declined complete graft excision and is receiving lifelong suppressive antibiotic therapy. The other patient underwent complete graft excision and an NAIS reconstruction. There were no perioperative or procedure-related deaths. There were no major amputations, and primary graft patency was 92% at 72 months. The most common AFBG culture isolate was Staphylococcus species. Approximately one-third of cultures did not yield any growth. Patients underwent anywhere from 1 to 12 weeks of combined intravenous and oral antibiotic therapy. ConclusionsThis limited series demonstrates excellent graft patency with a low persistent infection rate. Thus, in patients with localized graft infection, partial excision with preservation of the proximal synthetic graft is an acceptable alternative when patient factors preclude complete graft excision.

Long-term experience with the E-vita Open hybrid graft in complex thoracic aortic disease†.

The E-vita Open hybrid stent graft is intended to achieve one-stage treatment of the proximal and distal thoracic aorta down to the mid-thoracic level in cases of acute (AAD) or chronic (CAD) type I aortic dissection and complex thoracic aortic aneurysm (TAA). We report our long-term results up to 10-year experience. From February 2005 until March 2015, 178 consecutive patients (mean age 59 ± 11 years) underwent surgery using the E-vita Open hybrid graft for AAD ( n = 96), CAD ( n = 43) or TAA ( n = 39). Pre-, intra- and postoperative variables, influential procedural improvements and follow-up data including aortic remodelling analyses are presented. Overall 30-day mortality was 10%, 10% for AAD, 7% for CAD and 13% for TAA. Univariable analysis identified low left ventricular ejection fraction, peripheral arterial disease, chronic obstructive pulmonary disease and severely compromised haemodynamics as risk factors for in-hospital death. Logistic regression analysis defined compromised haemodynamics and duration of cardiopulmonary bypass as significant. After 7 years, estimated survival was 55% for AAD, 74% for CAD and 73% for TAA patients. Freedom from aorta-related late death was 94%, 91% in AAD, 100% in CAD and 97% in TAA. Positive or stable aortic remodelling down to the stent graft end was achieved in 92% AAD, 82% in CAD and full aneurysmal exclusion in 88%. Further downstream, negative remodelling was observed in 27% of the AAD, 41% of the CAD and 22% of the TAA patients. Freedom from endovascular intervention downstream was 96% in AAD, 75% in CAD and 74% in TAA patients. Freedom from thoraco-abdominal surgery was 97%, 65% and 93%, respectively. The E-vita Open hybrid stent graft renders durable long-term performance without any proximal endoleakage or graft failure over time and represents the ideal landing or docking zone for either thoracic endovascular thoracic repair or thoraco-abdominal surgery, if required. No reinterventions were necessary down to the end of the stent graft, proving that the disease is overcome along the hybrid graft down to mid-thoracic level.

Endovascular Repair of Aortic Arch Aneurysm with Surgeon-Modified Fenestrated Stent Graft

Purpose: Early results of endovascular aortic arch aneurysm repair with fenestrated/branched endografts are promising. However, access to these devices in many regions of the world remains limited to a handful of centers participating in government-approved trials. This leaves patients living out of reach of these centers with limited or no treatment options. We describe a technique of treating aortic arch aneurysms with surgeon-modified fenestrated stent graft. Technique: The technique is demonstrated in an 80-year-old patient with a symptomatic 5.5 cm saccular aortic arch aneurysm that was successfully excluded with a surgeon-modified fenestrated Cook alpha proximal thoracic stent graft. The device comes with laser cut 3.5 mm barbs that do not permit retrograde resheathing. To overcome this, it was deployed, completely removed from its delivery system and a fenestration created to accommodate the left subclavian artery. A nitinol wire was withdrawn and used as a diameter-reducing wire that allowed for the device to be constrained posteriorly. Now mounted on its delivery system, the device was transitioned from a 24 French (Fr) sheath to a 20 Fr sheath to an 18 Fr sheath before advancing it into its original sheath. Under general anesthesia, the device was delivered into the thoracic aorta via a lunderquist wire placed from the right common femoral artery. The fenestration was cannulated from the left brachial artery access following partial device deployment and bridged with an Atrium iCAST stent graft. Conclusion: Endovascular repair of aortic arch aneurysms with surgeon-modified fenestrated Cook alpha proximal stent graft is feasible. The procedure has a potential for significant complications and should be performed in conjunction with an experienced cardiac surgery team.

A “Hybrid” Hybrid Approach - Aortic Debranching Using a Trifurcate Graft for Arch and Descending Thoracic Aortic Aneurysm Repair With the Thoraflex™ Hybrid Graft

Purpose: Pathology of the aortic arch and descending thoracic aorta poses many unique challenges for the cardiovascular surgeon. The Thoraflex™ hybrid device for the “frozen elephant trunk” procedure simplifies management of the descending thoracic aorta, whilst allowing anastomosis of the head and neck vessels to the proximal graft. We report our modification to the technique, involving the use of the Trifurcate Graft with Side Branch (Vascutek-Terumo Ltd, Ann Arbor, MI, USA) to improve the ease of arch vessel control and ensure continuous selective anterior cerebral perfusion. Methodology: Via median sternotomy and central cannulation, the patient is placed on cardiopulmonary bypass and cooled to 20 °C. The arch and neck vessels are identified. After cross-clamping and administration of cardioplegia, the brachiocephalic and left common carotid artery are anastomosed to the trifurcate graft between clamps, and perfusion to the head is maintained via the side branch. Following this, the arch is excised under a short period of circulatory arrest, and the Thoraflex™ hybrid graft is deployed into the descending aorta, and an anastomosis made to the sewing cuff. The proximal anastomosis is then made to the ascending aorta after re-establishment of systemic perfusion. The left subclavian artery is then anastomosed to the trifurcate graft, and the trifurcate graft is anastomosed to residual ascending aorta in an end-to-side fashion. Results: We have two cases that have been solved using this approach. We present surgical pictures, and intraoperative imaging.

New Markers in Atherosclerosis: Thrombospondin-2 (THBS-2) and Leukocyte Cell-Derived Chemotaxin-2 (LECT-2); An Immunohistochemical Study.

BackgroundCurrent research investigating the role of THBS2 and LECT-2 in atherogenesis is very limited. Therefore, we designed this study to demonstrate the role of THBS-2 and LECT-2 in atherosclerosis at the tissue level in fresh specimens.Material/MethodsA total of 32 patients who underwent coronary bypass surgery were enrolled. Aortic wall punch biopsies were obtained at the site of proximal aortosaphenous bypass graft anastomosis. A specimen of left internal mammarian artery (LiMA) was taken from the segment just proximal to its anastomosis. The aortic tissue is representive of the atherosclerotic tisue, and LiMA tissue is representative of the non-atherosclerotic area. The specimens were painted with CD68 for macrophage, and THBS-2 and LECT-2 antibodies for immunohistochemical staining.ResultsAortic THBS-2 levels were significantly lower, whereas aortic LECT-2 levels were significantly higher when compare to LiMA (14.4±9.9 (5–30) and 36.9±13.0 (5–60) p: 0.0001 and 20.3±15.0 (5–60) and 20.8±13,8 (10–30) p: 0.0001, respectively). CD68+ and monocyte level correlated significantly with AHA atherosclerosis grade (p=0.01, r=0.45 and p=0.001, r=0.56, Spearman’s test). CD68+ level correlated significantly with LECT-2 levels in atherosclerotic aortic tissue (p=0.026, r=0.392, Spearman’s test), whereas aortic TSBN-2 levels were not.ConclusionsThe present study has taken the first steps to highlight new markers in atherosclerosis by using immunohistochemical method. The study results suggest that the tissue levels of THBS2 and LECT-2 may correlate with the stage of atherosclerosis.