Proximal Graft Research Articles

Spasm and Reopening of the Right Gastroepiploic Artery Conduit After Coronary Artery Bypass Grafting

The right gastroepiploic artery (RGEA) has advantages for use as an arterial conduit in coronary artery bypass graft surgery but perioperative spasm often develops. This study assessed the spasm and occlusion rates of RGEA conduits and elucidated the mechanism of reopening of occluded RGEA conduits. Patients who received an RGEA conduit in coronary artery bypass graft surgery were studied (n= 976; 700 composite, 276 in situ, 16 free grafts; 16 received both in situ and composite grafts). Early, 1-year, and 5-year angiographies were performed in 961 patients (98.5%), 815 patients (83.5%), and 618 patients (63.3%), respectively. Graft spasm was demonstrated in early angiograms in 72 proximal graft trunks of 1,608 distal anastomoses (4.5%) constructed using an RGEA conduit. Early occlusion rates of composite, in situ, and free RGEA conduits were 1.1%, 2.5%, and 0%, respectively; 8.5%, 7.5%, and 21.4%, respectively, at 1 year; and 10.5%, 14.1%, and 37.5%, respectively, at 5 years. Nineteen of 23 patients who had RGEA conduit occlusions at early angiography (1 occluded anastomosis per patient) were reevaluated at 1 year, and 9 of them (47.4%) had become patent. Of 83 patients with occluded RGEA composite grafts (90 occluded RGEA conduit anastomoses) at 1-year angiography, 8 were reopened at 5 years (8.9%). Progression of native target coronary artery disease was observed in all 8 patients with reopened occluded RGEA conduits at 5 years but not in 9 patients with reopened RGEA conduits at 1 year. Reopening of occluded RGEA conduits occurred early and midterm postoperatively. Reopening appeared related to recovery from graft spasm, and could occur as late as midterm if associated with progression of native coronary artery disease.

Bentall Procedure with Concomitant Coronary-Coronary Bypass for Right Coronary Artery Stenosis: A Case Report

Abstract Introduction: Aortic surgery hasmademuch progress recently. Yet the combination of aortic surgery and coronary artery bypass grafting has remained amajor issue for the surgeons. Patient and Observation: Herein, we present a case of severe aortic insufficiency with aortic aneurysm concomitant with single coronary artery disease on the right coronary artery. The patient underwent Bentall procedure for the correction of severe AI and aortic aneurysm. Subsequently, due to the lack of proper site for proximal anastomosis of the saphenous veingraft on the ascending aorta, we decided to performcoronary-coronary artery bypass for the right coronary artery lesion instead of conventional implan- tation of saphenous vein graft on the ascending aorta. Conclusions: Coronary-coronary artery bypass could be performed safely for special conditions like porcelain aorta and when the ascending aorta is not suitable for the proximal saphenous vein graft.

Revascularisation pattern of ruptured flexor tendon grafts in anterior cruciate ligament reconstruction: A histological study

IntroductionFor successful anterior cruciate ligament (ACL) reconstruction, revascularisation and histological maturation are necessary, as their failure can cause graft rupture. PurposeThe purpose of this study was to describe differences in the histological maturation of early failed plasty (less than 12 months after surgery) and late failed plasty (more than 12 months after surgery) in patients with re-rupture after ACL reconstruction with hamstring tendons. Material and methodsA descriptive observational study was conducted on a consecutive series of 20 patients whose ACL reconstruction had failed. Graft biopsy samples were obtained during the revision surgery from the proximal, medial, and distal graft remnants. The samples were evaluated by light microscopy, and the vascularity and maturation of the samples were established by histological scoring. ResultsThe most common aetiology of reconstruction failure (86.6%) was a specific event with non-contact mechanism. The patients with re-rupture of their ACL plasty less than 12 months after surgery had substance vessels that were less deep. The distal segment of the graft in those patients showed a delay in histological maturation with fewer collagen fibres. ConclusionIn patients whose ACL grafts failed less than 12 months after surgery, a lower distribution of blood vessels and collagen fibres was found that were less ordered in the distal graft. These results indicate a delay in maturation, which leads to a higher risk of graft failure.

Patrón de revascularización de injertos de tendones flexores rotos en reconstrucción de ligamento cruzado anterior: un estudio histológico

IntroductionFor successful anterior cruciate ligament (ACL) reconstruction, revascularisation and histological maturation are necessary, as their failure can cause graft rupture. PurposeThe purpose of this study was to describe differences in the histological maturation of early failed plasty (less than 12 months after surgery) and late failed plasty (more than 12 months after surgery) in patients with re-rupture after ACL reconstruction with hamstring tendons. Material and methodsA descriptive observational study was conducted on a consecutive series of 20 patients whose ACL reconstruction had failed. Graft biopsy samples were obtained during the revision surgery from the proximal, medial, and distal graft remnants. The samples were evaluated by light microscopy, and the vascularity and maturation of the samples were established by histological scoring. ResultsThe most common aetiology of reconstruction failure (86.6%) was a specific event with non-contact mechanism. The patients with re-rupture of their ACL plasty less than 12 months after surgery had substance vessels that were less deep. The distal segment of the graft in those patients showed a delay in histological maturation with fewer collagen fibres. ConclusionIn patients whose ACL grafts failed less than 12 months after surgery, a lower distribution of blood vessels and collagen fibres was found that were less ordered in the distal graft. These results indicate a delay in maturation, which leads to a higher risk of graft failure.

A biomechanical study of proximal tibia bone grafting through the lateral approach

BackgroundAutologous bone graft remains the gold standard source of bone graft. Iliac crest has traditionally been the most popular source for autologous bone graft. However, iliac crest bone graft harvesting is associated with high donor site morbidity. Bone graft harvesting from the proximal tibia has shown great potential with reported low complication rates. However, there is a paucity of biomechanical studies concerning the safety as well as yield of proximal bone graft harvesting. PurposeThis biomechanical study was designed to investigate (1) the stability of the harvested proximal tibial during physiological loading, and (2) the maximum size of the cortical window that can be safely created and (3) volume of accessible bone graft. MethodsBone grafts were harvested from eleven cadaveric tibiae using a circular cortical window along the lateral proximal tibia. These harvested proximal tibiae were then loaded under physiological conditions (mean 2320N, range 1650–3120N) using a customized test fixture. Strain rosettes were mounted at 7 locations in the harvested proximal tibia to record the changes in strain at the harvested proximal tibia. The change in strain with increasing cortical window size (10–25mm diameter) was also studied. Bone principal strains as well as volume of bone harvested were recorded. ResultsA repeated measures ANOVA was used to analyze the change in bone strains with the cortical window size. Statistically significant (p<0.05) increases in bone strains at the anterior and medial aspects of the tibia were observed with increasing size of osteotomies (−328.85με, SD=232.21 to −964.78με, SD=535.89 and 361.64με, SD=229.90 to −486.08με, SD=270.40 respectively), and marginally significant changes in strain at the lateral and posterior aspects. None of the tibiae failed under normal walking loads even with increasing osteotomies size of 10–25 mm diameter. A smaller osteotomy of 10mm diameter yielded an average volume of 7.15ml of compressed bone graft, while a larger osteotomy of 25mm diameter yielded on average an additional 3.64ml of bone graft. Bone grafting of the proximal tibia through the lateral approach with a circular osteotomy is a feasible option even with osteotomies of 25mm diameter. Even though increased bone strains were observed, the strains did not exceed the yield strain of cortical bone when loaded under normal walking conditions. The quantity of bone harvested from the proximal tibia is comparable to that harvested from the iliac crest. ConclusionsThis biomechanical study demonstrated the stability of the harvested proximal tibia under conditions of full weight bearing ambulation. It has also refined the technique of proximal bone graft harvesting by determining the maximum size of the cortical window. The findings of this study add to the overall understanding of proximal tibial bone graft harvesting, providing objective data regarding stability as well as yield. This information would be useful during selection of source of autologous bone graft.

Clinical Outcome of En-Bloc Resection of Distal Radius Giant Cell Tumor And Reconstruction by Non Ascularized Fibular Graft &amp;Transossious Augmentation of Wrist By PalmarishLongusTendon,An Improvise Technique

Introduction: Giant cell tumor (GCT) of bone is a benign but locally aggressive tumor with tendency for local recurrence. Usually it can be treated by en-bloc resection and reconstruction arthroplasty using autogenous non-vascularizedipsilateral proximal fibular graft. Fibulo-carpal subluxation can be prevent by transossiouspamarishlongus tendon. This improvise technique found useful in preserving the movements and functions as well as stability of the wrist. Materials and Methods: Ten patients with a mean age of 33 years, witheither Campanacci grade II or III histologically proven giant cell tumours of lower end radiuswere treated with wide excision and reconstruction with ipsilateral non-vascularised proximalfibularautograft. Host graft junction was fixed with dynamic compression plate (DCP) in allcases. Wrist ligament reconstruction and fixation of the head of the fibula with carpal bonesand distal end of the ulna using K-wires along with pamarishlongus tendon reinforcement throw transeossiciousroot and primary cancellous iliac crest grafting at grafthost junction was done in all cases. Results: The follow-up ranged from 30 to 60 months (mean,46.8). At last follow-up, the average combined range of motion was 100° with range varyingfrom 60° to 125°. The average union time was 7 months (range, 4 to 12). Non-union occurredin 1 case. Graft resorption occurred in another case. Localised soft tissue recurrence occurredin another case after 3 years and was treated by excision. There was no case of graft fracture,metastasis, death, local recurrence or signifi cant donor site morbidity. A total of 3 secondaryprocedures were required. Conclusions: Enbloc resection of giant cell tumours of the lowerend radius is a widely accepted method. Reconstruction with non-vascularised fibular graft,internal fixation with DCP with primary corticocancellous bone grafting with transfixation of the fibular head and wrist ligament reconstruction minimises the problem and gives satisfactoryfunctional results.

The Relationship between Temporal Changes in Proximal Neck Angulation and Stent-Graft Migration after Endovascular Abdominal Aortic Aneurysm Repair

In recent years, endovascular abdominal aortic aneurysm repair (EVAR) fortreating abdominal aortic aneurysms (AAA) has become quite prevalent in Japan. Thoughlittle information is available about temporal changes in proximal neck angulation due to the difficulties encountered in measuring the angle. Therefore, we examined temporalchanges in proximal neck angulation and its relationship to stent-graft migration after EVAR. Between June 2007 and March 2010, 159 patients underwent EVAR for treatment of fusiform AAAs at our hospital. This study focuses on the 80 patients among this group whose treatment sites and subsequent stent grafts were examined by contrast computed tomographic angiography before surgery, directly after surgery (within 4days), as well as 1year and 2years thereafter. We created curved planar reconstruction (CPR) images and measured the length of migration and neck angle using our method. At 2years after EVAR, the average length of proximal landing zone was 21.4±9.2mm. The average length of stent migration after 2 years was 1.41±2.68mm. The average neck angle was 33.9° preoperatively and 29.9° directly after surgery yielding a significant difference. However, 1 and 2 years after surgery the average neck angle was 28.2° and 28.4°, respectively. The number of patients experiencing a change >6° in the angle of the proximalneck between the preoperative condition and that directly after surgery was 16 (34.8%) with the use of Zenith stent grafts (n=46) and 14 (41.2%) with the use of Excluder stent grafts (n=34). There was no correlation between the proximal neck angle and migration of the proximal stent graft. In addition, there was no correlation between the changes in proximal neck angle and the secondary intervention rate and the occurrence of endoleak. There was a significant change in the neck angle between the preoperative condition and the immediate postoperative condition. However, there was no clear relationship found between the angle of the neck and the proximal stent-graft migration. Postoperative changes in the proximal neck angle just after EVAR and subsequent temporal changes during a 2-year follow-up period do not appear to predict stent-graft migration, secondary intervention rates, or the occurrence of endoleak.

Directional Control for Precise Deployment of Endovascular Aneurysm Repair and Thoracic Endovascular Aortic Repair in Angulated Anatomy

Endovascular stent graft repair of aortic aneurysms has become the standard in most centers. Several anatomic constraints still prevent or compromise the use of this technology. Angulated infrarenal aortic necks or steep aortic arches may result in erratic stent graft deployment with inadvertent branch vessel coverage, inadequate lesion coverage, or bird beaking. We have developed a technique using off-the-shelf equipment to precisely control the deployment of stent grafts in challenging landing zones. Two patients with challenging proximal landing zones were treated by this technique. The first patient, a 72-year-old man, was treated with a Gore Excluder device (W. L. Gore & Associates, Flagstaff, Ariz) for a 5.6-cm infrarenal aortic aneurysm with an angulated neck. A standard J wire was passed through the device, captured with an endosnare, and removed through a Destino sheath (Oscor, Palm Harbor, Fla) in the contralateral groin. The through-and-through wire and sheath allowed the precise deflection of the device along the angulated neck. The device was deployed while deflected. The remainder of the case was unremarkable. The second patient was an 84-year-old man who developed a descending thoracic aortic intramural hematoma with acute enlargement and pseudoaneurysm in the setting of type III aortic arch. In the operating room, two GORE CTAG thoracic stent grafts were built up from the celiac into the proximal descending thoracic aorta. A final proximal stent graft was advanced into approximate position. Left brachial access was established, and a J wire was brought through and through from the stent graft into a 5F MPA catheter in the left brachial sheath. Through a combination of wire traction and forward force on the MPA catheter, the device was precisely positioned onto the lesser curve. The graft was deployed orthogonally at the level of the left carotid. A left subclavian snorkel was planned preoperatively and was placed. In both cases, technical success was attained. Follow-up imaging at 6 weeks in each case demonstrated continuous wall apposition and no endoleak. Anatomic constraints have limited or complicated the use of endovascular stent grafts for some aortic disease. The use of a through-and-through flexible wire and a stiff catheter or sheath allows precise placement in these challenging landing zones.

Reoperative Aortic Root Replacement in Patients with Previous Aortic Root or Aortic Valve Procedures.

BackgroundGeneralization of standardized surgical techniques to treat aortic valve (AV) and aortic root diseases has benefited large numbers of patients. As a consequence of the proliferation of patients receiving aortic root surgeries, surgeons are more frequently challenged by reoperative aortic root procedures. The aim of this study was to evaluate the outcomes of redo-aortic root replacement (ARR).MethodsWe retrospectively reviewed 66 patients (36 male; mean age, 44.5±9.5 years) who underwent redo-ARR following AV or aortic root procedures between April 1995 and June 2015.ResultsEmergency surgeries comprised 43.9% (n=29). Indications for the redo-ARR were aneurysm (n=12), pseudoaneurysm (n=1), or dissection (n=6) of the residual native aortic sinus in 19 patients (28.8%), native AV dysfunction in 8 patients (12.1%), structural dysfunction of an implanted bioprosthetic AV in 19 patients (28.8%), and infection of previously replaced AV or proximal aortic grafts in 30 patients (45.5%). There were 3 early deaths (4.5%). During follow-up (median, 54.65 months; quartile 1–3, 17.93 to 95.71 months), there were 14 late deaths (21.2%), and 9 valve-related complications including reoperation of the aortic root in 1 patient, infective endocarditis in 3 patients, and hemorrhagic events in 5 patients. Overall survival and event-free survival rates at 5 years were 81.5%±5.1% and 76.4%±5.4%, respectively.ConclusionDespite technical challenges and a high rate of emergency conditions in patients requiring redo-ARR, early and late outcomes were acceptable in these patients.

Tibial Bone Grafting for Wrist Reconstruction.

Background Iliac crest bone graft harvesting is routinely performed for upper extremity orthopedic procedures despite high complication rates associated with sensory nerve injury, hematoma, chronic pain, and fracture. Description of Technique Cancellous bone graft is harvested from the proximal tibia using a medial approach, minimizing donor site morbidity. Patients and Methods A retrospective review was undertaken of 14 patients who underwent cancellous proximal tibia bone graft harvesting to augment healing of wrist reconstruction, with 2 months minimum follow-up. We report donor limb tourniquet time, time to union, visual analog scale (VAS) pain score, and complications. Patients were also contacted by phone to administer a retrospective questionnaire and record experiences with the harvesting technique. Results Average donor site VAS for the immediate postoperative period was 7.4. Average tourniquet time was 28 minutes. Average time to union of the recipient site was 45 days. One patient experienced delayed union after corrective osteotomy, attributed to osteoporosis. Two patients underwent hardware removal from the operative wrist, unrelated to bone graft harvesting. One patient with a history of chronic neuropathy and foot drop developed dysesthesia and allodynia about the ipsilateral ankle, but was asymptomatic at the proximal tibia donor site; ankle symptoms resolved 3 weeks postoperatively. No patient reported any residual donor site difficulties 24.2 months postoperatively. Conclusion In consideration of the minimal complication rate, favorable clinical parameters, and excellent patient tolerance, we advocate proximal tibia bone graft harvesting as opposed to iliac crest harvesting for wrist reconstruction when a moderate amount of autogenous cancellous graft is needed. Level of Evidence IV.

Composite sequential bypass using profunda vein hitchhike

Patients with long-segment occlusions of the iliac and femoral arteries often undergo sequential bypass procedures. There exists a subgroup of patients who have no suitable vessels in the groin. We report our experience with a new technique of using the profunda vein as a hitchhike point in our series of seven patients (eight limbs) with critical ischemia and occlusion at the iliac or aortic level with reformation of infrageniculate arteries and no reformation in the groin. The proximal graft was anastomosed to the profunda vein, which was ligated proximal to the anastomosis. The saphenous vein graft was taken from the distal end of the polytetrafluoroethylene graft and anastomosed to the appropriate tibial arteries. The procedure was technically successful in all the patients. The median follow-up was 8months (range, 0-30). The profunda vein as a hitchhike point gives an excellent outcome in the short and medium term in this uncommon group of patients.

Diagnostic accuracy and effective radiation dose of high pitch dual source multidetector computed tomography in evaluation of coronary artery bypass graft patency

The aim of the study was to evaluate the diagnostic accuracy and effective radiation dose (ERD) of high pitch dual source multidetector computed tomography (MDCT) for coronary artery bypass graft (CABG) patency. Fourty-five patients who underwent 128× 2‑slice MDCT angiography with aprospective electrocardiogram-triggering, low-dose, high pitch, dual source, flash spiral acquisition mode after CABG surgery were included in the study. The interobserver agreement of the image quality was evaluated with Cohen κvalue. The image quality was compared to the heart rates (HRs) using Mann-WhitneyU test and to the graft segments using χ(2) test. The findings for the CABG patency on MDCT were compared to those determined on catheter coronary angiography. Dose-length product (DLP) and ERD were compared to the gender, HRs, and body mass index (BMI) of the patients using Kruskall Wallis and Mann-WhitneyU tests. Atotal of 110 grafts and 330 vessel segments were evaluated with agood interobserver agreement (κ= 0.80). The image quality was better in proximal and middle graft segments (p< 0.05), as well as in the patients with low HRs (p< 0.05). High pitch MDCT had the following sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy for evaluation of graft patency: 92.8, 99.3, 92.8, 99.3 and 98.8 %, respectively. ERD was correlated to the HRs and BMI. High pitch 128× 2‑slice dual source CT angiography is anoninvasive imaging modality, and it can be safely and effectively used in evaluation of CABG patency with lower radiation dose.

Anatomic features of the distal aortic arch that influence endovascular aneurysm repair

Successful thoracic endovascular aneurysm repair (TEVAR) is contingent on seal and fixation of the proximal graft. The aortic arch has a wide range of anatomic variability, and understanding that anatomy may optimize device deployment. The purpose of this study was to assess aortic arch anatomic features that influence zones 2 and 3 TEVAR and specifically to quantitate the impact of gantry angle correction on proximal seal zone for patients with proximal descending thoracic aortic disease. Sixty patients with descending thoracic aortic pathology that would require TEVAR with a zone 2 or 3 deployment were evaluated. Demographic and imaging data were retrospectively reviewed. Computed tomography scans were evaluated using a 3-dimensional workstation for centerline and angle analyses. The optimal gantry angle was determined to be the orthogonal view of the leading (proximal) edge of the seal zone based on a manual adjusted centerline. Measurements were then taken of the seal zone at-10° and-20° from optimal view to assess the impact of imperfect gantry angle correction. The study included 38 men (63%) with a mean age of 66years (range, 24-90 years). Thirty-eight (63%) required zone 2 deployment. Zone 2 seal zones were shorter and required less gantry angulation for an optimal view than were zone 3 seal zones. Incomplete gantry angle correction affected expected use of both zone 2 and 3 seal zones similarly. At 10° and 20° from optimal gantry angel, the loss in use of available seal zone length is estimated to be 2.4± 1.1 and 6.2± 2.3mm, or 10% and 25%, respectively. These results were not different for men or women, nor were they influenced by age, sex, body mass index, height, or etiology of aortic pathology. Inner and outer curvature measurements differed by 80%. Only four patients (7%) had a zone 1 segment ≥ 5mm in length. Optimal gantry angle correction should be the goal of any TEVAR procedure. Zone 2 seal zones require less gantry angulation than zone 3 seal zones by nearly 20°. This study shows that correction within 10° of optimal isunlikely to significantly impact successful seal and fixation for most patients. At 20°, however, substantial loss of seal zone can be expected. Measurements of the inner and outer curvature reveal different information about the distal archand should be assessed individually. Zone 1 deployment rarely provides meaningful additional seal zone length.

Comparison of Radial Artery and Saphenous Vein Graft Stenosis More Than 5 Years After Coronary Artery Bypass Grafting

Graft stenosis may be associated with future graft failure. The purpose of this investigation was to compare graft stenosis between radial artery (RA) grafts and saphenous vein grafts (SVGs) at least 5 years postoperatively using the multicenter Radial Artery Patency Study (RAPS) data. Two hundred thirty-four patients underwent late invasive angiography after coronary artery bypass operations. The study population consists of 163 patients with thrombolysis in myocardial infarction (TIMI) 3 flow of both the RA graft and study SVGs. Angiograms were reviewed centrally and in a blinded fashion. Graft stenosis was recorded for the proximal anastomosis, graft body, and distal anastomosis; significant stenosis was defined as greater than or equal to 50%. Major adverse cardiac events (MACE) were reported in patients with and those without significant graft stenosis. There was no difference in significant graft stenosis of the patent RA grafts and SVGs (14 of 163 [8.6%] versus 19 of 163 [11.7%]) or in the proximal anastomosis (5 of 163 [3.1%] versus 5 of 163 [3.1%]), graft body (6 of 163 [3.7%] versus 13 of 163 [8.0%]), or distal anastomosis (4 of 163 [2.5%] versus 5 of 163 [3.1%]) considered separately. However, the overall burden of graft body disease was higher in SVGs (p= 0.03). MACE was higher in patients with significant graft stenosis than in patients without stenosis (10 of 28 [35.7%] versus 7 of 135 [5.2%]; p< 0.0001). There was no significant difference in the rates of significant stenosis of patent RA grafts and SVGs more than 5 years postoperatively. However, the burden of graft body stenosis was less in RA grafts compared with SVGs, suggesting that the RA grafts will continue to outperform the SVGs late after operation.

Safety and Efficacy of Sequential Left Internal Thoracic Artery Grafting to Left Circumflex Area

This study investigated short-term and long-term results of coronary artery bypass grafting (CABG) with in situ sequential left internal thoracic artery (LITA) grafting to the left circumflex area. The study divided 452 patients who underwent CABG with bilateral ITA grafting to the left coronary artery into two groups: 191 in the sequential group and 261 in the individual group. The 147 pairs were matched by the propensity score. In the matched pairs, the rates of off-pump, complete revascularization, and hospital death were comparable between the two groups. Early graft evaluation was performed in 78.6%. There was no occlusion of the sequential LITA graft itself, but 5 complications occurred involving the distal segment of the LITA graft (occlusion, 2; string, 2; and competition, 1), and 3 complications (occlusion, 2; and string, 1) developed in the individual group. Event-free anastomosis rates were 97.8% in the sequential group and 97.4% in the individual group (p= 0.847). Diamond anastomosis of proximal sequential grafting showed a better patency of the distal part of sequential anastomosis compared with a parallel anastomosis of proximal sequential grafting (98.4% vs 90.7%, respectively). The freedom from target lesion revascularization and overall survival at 8 years was 94.6% and 96.3% in the sequential and individual groups, respectively (log-rank p= 0.645) and 80.7% and 77.4% (p= 0.300), respectively. In situ sequential LITA grafting provides acceptable early graft patency and freedom from repeat revascularization, resulting in excellent survival. This technique is a useful strategy for multivessel revascularization including the left circumflex area.

Length of Vascularized Fibula Graft Utilized and Union: Is There a Relationship?

Background Vascularized fibula grafting is used in the treatment of large skeletal defects, recalcitrant atrophic nonunions, and infected nonunions. Few studies have examined the factors contributing to nonunion of the graft at one or both graft–recipient junctions. The purpose of this study was to determine if a correlation exists between length of the graft and primary union of the graft–recipient interface at the proximal and/or distal junction. Methods A total of 21 patients who underwent vascularized fibula grafting from 2002 to 2014 for the treatment of skeletal defects were included. Radiographs were assessed for union of the graft at the proximal and distal junctions. The rates of union at the proximal and distal junctions were determined with respect to the limb and graft. The relationship between the length of graft utilized and union was assessed. Results A total of 71.4% of patients, with an average follow-up of 30.2 months, achieved complete union at an average of 8.7 months. With respect to the limb, a union rate of 95.2% was achieved at the distal graft–recipient junction versus 71.4% at the proximal junction ( p = 0.038). With respect to the graft orientation, a union rate of 90.5% was achieved at the distal graft versus 76.2% at the proximal graft ( p = 0.214). The length of the graft did not have a significant correlation to the rate of union. Conclusion The length of the fibula graft does not have an association with the rate of primary union. If primary union is not achieved, likely the nonunion will have occurred at the proximal graft–recipient junction.

The Provisional Extension To Induce Complete Attachment (PETTICOAT) technique to promote distal aortic remodelling in repair of acute DeBakey type I aortic dissection: preliminary results.

To report our preliminary results of an aggressive technique, the Provisional Extension To Induce Complete Attachment (PETTICOAT), in repair of acute DeBakey type I aortic dissection. From April 2014 to November 2014, 18 patients with acute DeBakey type I aortic dissection were reviewed retrospectively. Nine patients underwent open repair combined with proximal stent grafting and distal bare stenting (PETTICOAT group). For comparison, another 9 patients underwent open repair combined with proximal stent grafting (NON-PETTICOAT group) were included. Open repair entailed ascending aorta plus total arch replacement under circulatory arrest, with variable aortic root work. Mortality and morbidity were recorded, and computed tomography was performed to evaluate the aortic remodelling at 6 months postoperatively. Preoperative parameters were similar. In the PETTICOAT group, one early mortality was noted. One complication of cardiac tamponade and sternal wound infection led to reopen surgeries. In the NON-PETTICOAT group, one case of transient ischaemic attack took place. Compared with the NON-PETTICOAT group, a significant increase in diameter of true lumen (median, 0.6 vs 0.1 mm, P < 0.01) and a decrease in diameter of false lumen (FL; median, -0.9 vs 0.0 mm, P < 0.01) at the level of lowest renal artery were noted in the PETTICOAT group. Moreover, significant FL volume regression (median, -102.0 vs -42.2 mm(3), P = 0.03) was observed in the PETTICOAT group. More cases of total thrombosis or regression of FL down to the level of renal artery were also noted in the PETTICOAT group (5/8 vs 0/9, P < 0.01). Two patients of the NON-PETTICOAT group received endovascular distal aortic reintervention at 6 months. The PETTICOAT technique in the management of acute DeBakey type I dissection is a feasible and promising method to promote distal aortic remodelling. However, outcomes are preliminary and further follow-up is required.

Establishment of a rat and guinea pig aortic interposition graft model reveals model-specific patterns of intimal hyperplasia

Although the aortic interposition bypass model has been widely used to evaluate biomaterials for bypass grafting, there is no comprehensive description of the procedure or of the distribution of intimal hyperplasia that results. The objectives of this study were to (1) review and summarize approaches of aortic interposition grafting in animal models, (2) determine the pertinent anatomy for this procedure, (3) validate this model in the rat and guinea pig, and (4) compare the distribution of intimal hyperplasia that develops in each species. A literature search was performed in PubMed from 1980 to the present to analyze the use of anesthesia, anticoagulation, antiplatelet agents, graft material, suture, and anastomotic techniques. Using 10-week-old male Sprague-Dawley rats and Hartley guinea pigs, we established pertinent aortic anatomy, developed comparable models, and assessed complications for each model. At 30days, the graft and associated aorta were explanted, intimal formation was assessed morphometrically, and cellularity was assessed via nuclear counting. We reviewed 30 articles and summarized the pertinent procedural findings. Upon establishing both animal models, key anatomic differences between the species that affect this model were noted. Guinea pigs have a much larger cecum, increased retroperitoneal fat, and lack the iliolumbar vessels compared with the rat. Surgical outcomes for the rat model included a 53% technical success rate and a 32% technical error rate. Surgical outcomes for the guinea pig model included a 69% technical success rate and a 31% technical error rate. These two species demonstrated unique distribution of intimal hyperplasia at 30days. Intimal hyperplasia in the rat model was greatest at two areas, the proximal graft (5400 μm2; P< .001) and distal graft (2800 μm2; P< .04), whereas the guinea pig model developed similar intimal hyperplasia throughout the graft (4500-5100 μm2; P< .01). In this report, we summarize the literature on the aortic interposition graft model, present a detailed description of the anatomy and aortic interposition graft procedure in the rat and guinea pig, and describe a unique distribution of intimal formation that results in both species. This information will be helpful when designing studies to evaluate novel graft materials in the future.

Proximal Medial Tibial Bone Graft Harvesting in Foot and Ankle Surgery

ABSTRACT Cancellous bone graft harvesting from proximal tibia is usually by a lateral approach. We describe our technique and results in harvesting proximal tibia bone graft by a medial approach in foot and ankle surgery. Our results confirm that medial proximal tibial bone graft harvesting is a relatively safe and easy procedure to obtain adequate amount of autogenous cancellous bone graft. Donor site morbidity was found to be very low and fusion rate was found to be excellent in a variety of foot and ankle surgeries. How to cite this article Dalal R, Sugathan HK, Rachha R. Proximal Medial Tibial Bone Graft Harvesting in Foot and Ankle Surgery. J Foot Ankle Surg (Asia-Pacific) 2016;3(1):6-9.

Concomitant bentall-de bono procedure plus total arch replacement and coronary artery bypass grafting in acute aortic dissection

We report the images of a case of a 31-year-old male presented with acute Type A aortic dissection with severe aortic regurgitation involving the arch vessels. He was taken up for surgery on cardiopulmonary bypass (femoro-axillary-bicaval). Bentall-De Bono procedure with mechanical aortic valved conduit and total arch replacement with woven polyester branched graft under hypothermic circulatory arrest plus selective antegrade cerebral perfusion was performed. Reversed saphenous venous graft to proximal right coronary artery grafting was also performed.