Reconstructive Vascular Surgery Research Articles

Abstract Mo032: Biofabrication of Small Vascular Graft using Human Amniotic Membrane

Vascular diseases encompass a spectrum of pathological conditions affecting blood vessels, including cerebrovascular disease, coronary heart disease, aneurysms, deep vein thrombosis, and peripheral arterial disease. In severe cases, surgical interventions such as bypass grafting or vascular replacement surgeries are necessary to restore blood flow by bypassing obstructed vessels with functional vascular substitutes. Autologous blood vessels harvested from patients are considered the gold standard for vascular surgeries. However, their availability is limited in patients with pre-existing chronic diseases or previous vessel harvest, and the associated morbidities of vessel harvesting and subsequent surgeries further restrict their therapeutic applicability. Synthetic grafts, including polytetrafluoroethylene (e-PTFE), polyethylene terephthalate (PET), and polyurethane (PU), have obtained FDA approval for clinical application and have shown satisfactory outcomes in large vessel surgeries (internal diameter > 6mm). However, clinical trials targeting medium (6-10 mm) to small (< 6mm) vessels often yield unsatisfactory results. This study aims to develop a small vascular graft using human amniotic membrane (HAM) that meets the structural, mechanical, and biological requirements for human vascular reconstructive surgeries. Fresh HAMs were decellularized with 1% Triton X-100 and 0.1% sodium dodecyl sulfate to prepare decellularized HAM (DAM). The DAM was trimmed into a rectangular shape and rolled around a catheter to prepare a tubular-shaped DAM vascular graft. After rolling, the DAM grafts were crosslinked with 1% genipin for 24 hours followed by thorough water washing. The final DAM vascular graft exhibited a multi-layered wall structure and comparable dimensions and mechanical properties to native arteries. The DAM vascular graft was further evaluated in vivo by replacing part of the rat abdominal aorta and part of the carotid artery in pigs. Both small and large animal studies demonstrated vascular patency with no neointimal hyperplasia (NIH), suggesting that the DAM graft holds significant promise as a small tissue-engineered vascular graft for future vascular reconstruction surgeries.

History of Reconstructive Vascular Surgery

This article reflects the history of the development of reconstructive surgery of vascular surgery. From the history it has been found out that reconstructive vascular surgery has achieved certain achievements and was a young branch of clinical surgery. Reconstructive surgery made it possible to continue life with severe vascular pathologies, which in most cases lead to death. The article reflects various clinical cases after certain methods of treatment, after which there are positive results. The history of the literature review describes the methods of surgery performed by various authors, who laid the foundation for reconstructive surgery and their invaluable experience, testifies to truly inexhaustible possibilities for continuing the path of vascular surgery.

Clinical outcomes after vascular reconstruction using synthetic grafts for limb salvage in patients with lower extremity sarcoma: a single-center retrospective experience.

Limb-salvage surgery has become the mainstream approaches for the treatment of sarcoma in the lower extremity. In cases where the sarcoma infiltrates the primary vessel, concurrent resection of the vessels and vascular reconstruction are required to ensure sufficient resection and preservation of limb function. The objective of this study is to assess the clinical outcomes of patients who underwent vascular reconstruction utilizing synthetic grafts for limb salvage, specifically in terms of postoperative complications and limb functional status. Between September 2016 and October 2021, 15 consecutive patients who underwent 15 arterial and 3 venous reconstruction procedures were included in this retrospective study. Incidence of postoperative morbidity, graft patency, rate of limb salvage, and overall survival of patients were analyzed. The median follow-up was 12.5 months (range, 4.5-72.0). Graft thrombosis occurred in 5 patients (33.3%) and graft occlusion occurred in 3 patients (20.0%). The median overall survival was 28.0 months with the estimated 2-year and 5-year overall survival of 57.8% and 43.4% respectively. The 1-year and 2-year estimated patency rates of arterial reconstructions were 82.3% and 62.1%, respectively. None of the included patients with limb amputation were observed as a consequence of severe vascular complications, while two patients underwent amputation due to the repeat recurrence, resulting in a limb salvage rate of 86.7%. Our results show that the combination of vascular reconstruction and oncologic resection is a feasible option for preserving limbs in cases of musculoskeletal sarcoma with vessel involvement in the lower extremity. When vascular reconstruction surgery is performed, synthetic substitutes can be effectively used with low perioperative morbidity and an acceptable rate of limb salvage.

Amyloid PET in patients with carotid occlusive disease: Preliminary results of the AMYCODE study

AbstractBackgroundCarotid occlusive disease (COD) is a risk factor for cognitive decline. One of the proposed underlying mechanisms is that cerebral hypoperfusion may result in accelerated accumulation of amyloid‐β in the brain. We hypothesized that patients with longstanding, unilateral COD have an asymmetrical burden of cerebral amyloid‐β, with more amyloid‐β in the hemisphere ipsilateral to the COD than in the contralateral hemisphere.MethodThe AMYCODE study is a cross‐sectional observational study. Inclusion criterion is a unilateral occlusion of the internal carotid artery. Exclusion criteria are: a contralateral stenosis of > 70% and a history of vascular reconstructive surgery. All patients underwent a neuropsychological assessment, MRI‐scan and dynamic 18F Florbetaben positron emission tomography scan (PET). Global relative perfusion (R1) and binding potential (BPND) were determined from the PET‐images using PMOD and a simplified reference tissue model with the cerebellar grey matter as reference region. Distribution Volume ratio (DVR) was calculated as BPND + 1. We performed Wilcoxon signed‐rank tests to examine differences between hemispheres within subjects.ResultTo date, we included eight participants (seven males, age 66.1±7.3 years, MMSE score 28.1±2.0; inclusion ongoing, target n = 20). Mean global DVR was 1.03±0.03 in the ipsilateral hemisphere (i.e. side of the occlusion) and 1.04±0.02 in the contralateral hemisphere (p = 0.064). Mean global R1 was 0.89±0.06 in the ipsilateral hemisphere and 0.91±0.05 in the contralateral hemisphere (p = 0.033).ConclusionPreliminary analyses suggest that patients with unilateral COD had similar amyloid‐β distribution, despite lower cerebral perfusion in the hemisphere ipsilateral to the COD than in the contralateral hemisphere.

Reconstructive vascular surgery in pediatric oncology: literature review

Background. In some rare cases pediatric solid tumors may infiltrate or incase major vessels, which may require vascular plastics as part of radical tumor resection. As these situations are rare in pediatric surgeon practice, there is no common approach to this problem. In order to analyze the available experience we reviewed published cases concerning vascular plastics in pediatric oncosurgery. Materials and methods. The references from MEDLINE (PubMed), HighWire Press, and eLibrary electronic databases were analyzed for references describing practical vascular surgery experience with vascular implants published in 2002–2022. Results. There is few published data on major vessels reconstruction in patients with pediatric solid tumors. Most publications describe single cases or small case series. The vascular plastics in these children is difficult due to small vessel diameter, difficulties in choosing the right graft, risk of thrombosis, and the need to provide adequate circulation in a rapidly growing child. As there are no major studies of this subject we still have no consensus on optimal vascular reconstruction tactics in children with solid tumors. Therefore, new systematic studies are needed. Conclusion. We provide a brief review on currently used methods of vascular plastics and reconstruction available for use in children with solid tumors.

Alternative Options of Blood Vessels Anastomosis

For a number of centuries, the problem of bleeding arrest from damaged vessels remains the major issue of surgery (alongside with infectious complications and fight against the pain syndrome). The development of vascular surgery began exactly when bleeding from a damaged vessel was arrested by tying it, and the introduction of reconstructive vascular surgery, being one of the most outstanding achievements of the 20th century, was the peak of creation. With the advent and development of this relatively young branch of clinical surgery, it became possible to effectively help patients with various vascular pathologies, previously considered incurable and doomed to death. However, the development of each industry is necessarily associated with the development of technical support. The lack of high-quality suture material and instruments has restrained the development of reconstructive vascular surgery for a long time; this fact forced researchers and surgeons to develop techniques for the seamless connection of blood vessels. Despite the widespread use of manual surgical suture, it is not always possible to use this option due to altered vascular walls. Development of technology for manufacturing synthetic materials allowed for techniques providing fast and high-quality connection of blood vessels, significantly reducing the time required for reconstruction and, as a result, reducing the incidence of complications.

Rupture infected pseudoaneurysm on brachiocephalic AV-fistula: emergency and definitive management

Background: Vascular access bleeding is a rare event that can be fatal in hemodialysis patients. It requires emergency and surgical management to reduce the risk of ischemic events in the patient’s forearm and reduce mortality risk. Objective: To describe the clinical presentation, emergency and surgical intervention, and outcome of rupture-infected anastomotic pseudo aneurysm of the brachiocephalic arteriovenous fistula that underwent a definitive surgical procedure. Case Description: A 55-year-old man presented with bleeding on the AV-fistula surgery site, accompanied with pain and swelling on his forearm that occurred 3 hours before admission to the hospital. The Patient had a history of brachiocephalic AV-fistula surgery 3 weeks earlier. On physical examination, It was found that the surgical site wound looked wet and swollen, with lots of necrotic tissue and pus and lost stitches. In Emergency Departments, the patient was administered intravenous normal saline fluids, bleeding inhibitors and pressure bandages to reduce ongoing bleeding. Then the patient had planned for immediate vascular reconstruction surgery. The brachial artery is repaired using great saphenous vein patch plasty. Results: The patient’s postoperative 30-days follow-up went well, and there was no sign of complication, such as pain, infection, paresthesia, bleeding at the surgical site or ischemia in the distal forearm. Conclusion: Vascular access bleeding can be fatal to hemodialysis patients. Optimal treatment for the patient's life and hemodialysis access is a top priority. A good assessment of the condition of AVF and the choice of subsequent therapy greatly affect the patient's prognosis.

First Femoropopliteal Bypass for a Critical Limb Ischemia

First Femoropopliteal Bypass for a Critical Limb Ischemia

Collagen-Sealed Polyester Vascular Prostheses Functionalized by Polycatecholamine Coatings.

Collagen-sealed polyester (PET) prostheses are commonly used in reconstructive vascular surgery due to their self-sealing properties. To prevent post-surgical infection, different modification methods have been tested but so far none have showed long-term satisfactory efficiency. For this reason, in the present study, a commercial collagen-sealed PET prosthesis was coated by a highly adhesive poly (L-DOPA) layer maintaining the sealing protein without losing the original properties and functionality. This modified (as proven by SEM, FTIR, XPS and contact angle) graft exhibited comparable wettability and elasticity as pristine commercial graft, as well as reduced hemolysis-inducing effect, lowered toxicity against human endothelial cells and reduced toxicity in Danio rerio model. Poly (L-DOPA)-coated grafts were shown to bind six times more aminoglycoside antibiotic (gentamicin) than pristine graft. Poly (L-DOPA)-coated antibiotic-bound prostheses exhibited an improved antibacterial activity (bacterial growth inhibition and anti-adhesive capacity) in comparison with pristine antibiotic-bound graft. Overall, poly (L-DOPA)-coatings deposited on PET vascular grafts can effectively functionalize collagen-sealed prostheses without the loss of protein sealing layer and allow for antibiotics incorporation to provide higher safety in biomedical applications.

Special Features of Polyester-Based Materials for Medical Applications.

This article presents current possibilities of using polyester-based materials in hard and soft tissue engineering, wound dressings, surgical implants, vascular reconstructive surgery, ophthalmology, and other medical applications. The review summarizes the recent literature on the key features of processing methods and potential suitable combinations of polyester-based materials with improved physicochemical and biological properties that meet the specific requirements for selected medical fields. The polyester materials used in multiresistant infection prevention, including during the COVID-19 pandemic, as well as aspects covering environmental concerns, current risks and limitations, and potential future directions are also addressed. Depending on the different features of polyester types, as well as their specific medical applications, it can be generally estimated that 25–50% polyesters are used in the medical field, while an increase of at least 20% has been achieved since the COVID-19 pandemic started. The remaining percentage is provided by other types of natural or synthetic polymers; i.e., 25% polyolefins in personal protection equipment (PPE).

Safety and efficacy of percutaneous coronary interventions performed via anatomical snuffbox access in elderly patients

Abstract Funding Acknowledgements Type of funding sources: None. Background Radial artery thrombosis is a potential complication of transradial catheterization. For elderly patients greater attention should be paid to preserve radial arteries due to rather common comorbidities, such as renal failure and systemic atherosclerosis. Radial arteries in such cases may be required for hemodialysis, coronary artery bypass grafting and vascular reconstruction surgery. Presumably, the distal radial access can provide additional benefits in reducing the incidence of radial artery occlusion. Purpose To evaluate the radial artery thrombosis incidence and other complications in elderly patients undergone a percutaneous coronary intervention via anatomical snuffbox radial access. Methods This research (Jan 2018 – Aug 2020) was conducted as a single-center, prospective study in 141 patients over the age of 75 who had a percutaneous coronary intervention via the conventional radial access (n = 57) and radial access in the anatomic snuffbox (n = 84). The primary endpoints were: thrombosis; radial artery spasm; cannulation site hematoma with a diameter larger than 1 cm; crossover to the different access. We also evaluated the time for access establishment and total duration of the procedure. Results The groups had no significant differences in age and sex (the mean age was 81.9 ± 4.6 years, 67.9% females). The percutaneous coronary intervention was performed for STEMI in 73 (51.2%) patients, NSTEMI in 39 (27.7%) patients, or CAD in 35 (21.1%) patients. Two (2.4%) cases of vascular access crossover were reported in the anatomical snuffbox group compared with two (2.6%) cases in the conventional radial access group (p = 0.684). There were no statistically significant differences in the access time between the groups. It was 3.43 ± 0.78 min in the conventional radial access group versus 3.28 ± 0.76 min (p = 0.891) in the anatomical snuffbox access group. The total duration of percutaneous coronary intervention was also comparable in two groups (44.1 ± 15.6 min versus 45.9 ± 16.5 min, p = 0.936). The radial artery occlusion incidence was significantly lower in the anatomical snuffbox access group compared with the conventional radial access group (2 (2.4%) versus 8 (14.5%), respectively, p = 0.008). Also, radial artery spasm occurred significantly less frequently in the anatomical snuffbox access group compared with the conventional one (2 (2.4%) versus 7 (12.7%), respectively, p = 0.018). The incidence of cannulation site hematoma was significantly lower in the anatomical snuffbox access group than in the conventional access group (5 (6%) versus 10 (18.2%), respectively, p = 0.025). Conclusion Access via the anatomical snuffbox reduces the incidence of radial artery occlusion, cannulation-related spasm, and cannulation site hematoma. So it may be considered preferred to conventional radial access in elderly patients. However, randomized studies are needed to further investigate these results.

Polycatecholamine and gentamicin as modifiers for antibacterial and blood-biocompatible polyester vascular prostheses

Polyester (PET) prostheses are commonly used in reconstructive vascular surgery. The most serious complication after implantation is early or late infection of the graft. Therefore, there is high demand to protect prosthesis against bacterial adhesion and biofilm development. For this reason, in this work PET prostheses were first coated by highly adhesive polycatecholamine layer. The grafts were then coupled with gentamicin and studied in relation to morphological and structural properties, biological safety (contact with blood, reaction of vascular endothelial cells (HUVEC), Danio rerio fish), drug release and antibacterial activity. Among two tested catecholamine monomers, L-DOPA was found to be more effective precursor in this process than dopamine. For L-DOPA, assistance of Cu2+, Mg2+ and Na+ ions seems to increase the amount of further immobilized drug. Coated prostheses exhibited greater human endothelial cell proliferation increase and lower cytotoxic effect than uncoated. The modification reduced the hemolysis observed for pristine commercial graft and limited the rate of abnormalities in D. rerio larvae, confirming the safety of the proposed modification. The coating allowed to double the amount of immobilized antibiotic in comparison with uncoated graft which resulted in increased antibacterial activity and reduced bacterial adhesion against 4 bacterial strains prevalent in biomaterials infections. Overall, poly(L-DOPA)-coatings deposited on PET vascular grafts can effectively functionalize these prostheses for higher safety in biomedical applications.

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

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

Ближайшие и отдаленные результаты хирургического лечения синдрома диабетической стопы и оценка качества жизни больных (обзор литературы)

В настоящее время при многих хронических заболеваниях все большее значение придается исследованию качества жизни (КЖ). Сахарный диабет (СД) в силу сложного режима контроля и лечения, а также многочисленных соматических проявлений (острых и хронических осложнений) оказывает выраженное воздействие на КЖ. КЖ, в свою очередь, оказывает значительное влияние на прогноз заболевания. В данном обзоре рассмотрены ближайшие и отдаленные результаты хирургического лечения синдрома диабетической стопы, определения КЖ и сходных понятий, освещены основные подходы к исследованию КЖ при СД, приведен перечень наиболее часто использующихся инструментов для оценки КЖ. Анализ публикаций показал, что до сих пор недостаточно проводилась системная проработка данной проблемы, не реализованы возможности современного уровня развития техники и информационных технологий для ее решения. Таким образом, несмотря на дальнейшее развитие сосудистой хирургии, многие вопросы, связанные с диагностикой и методами лечения больных с язвенно-некротическими поражениями нижних конечностей, остаются нерешенными. Качество диагностических и лечебных мероприятий по-прежнему зависит от профиля лечебного учреждения, наличия в нем отделения хирургии сосудов, субъективного отношения врачей к тем или иным методам лечения, их знаний и опыта в этой области. Наиболее эффективно решить данные проблемы и повысить качество диагностики, лечения и последующей жизни пациентов позволяет создание алгоритма, определяющего последовательность действий врачей при поступлении в стационар такого больного. Анализ литературы показал, что для более точной оценки ближайших и отдаленных результатов реконструктивных сосудистых операций у больных с диабетической ангиопатией необходимо использовать определение показателя КЖ и его параметров, что в дальнейшем позволяет выбрать наилучший способ оперативного лечения в каждом конкретном случае, а также выявить влияние хирургической операции или других видов лечения на психику пациента. По мнению некоторых авторов, имеющиеся классификации синдрома диабетической стопы неполно отражают клиническую картину осложнений, а следовательно, в большинстве случаев не определяют тактику лечения больных. Существуют различные мнения в отношении оперативно-хирургических приемов. Недостаточно полно и не всегда обоснованно описаны способы снижения послеоперационных осложнений, частота которых во многих клиниках превышает 30 %.

Single-center Experience With Vascular Reconstruction for Soft Tissue Sarcoma Resection

Resection of soft tissue sarcoma of the extremities may require vascular reconstructive surgery due to direct involvement or proximity of the tumor to major vascular structures. Autogenous conduit is preferred for vascular reconstruction, but is not always available. The purpose of this study is to evaluate long term survivorship and outcomes in sarcoma resection with vascular involvement or vascular reconstructive surgery and explore the utility of prosthetic conduit for soft tissue sarcoma resection requiring vascular reconstruction.

More Than 400 Uses of an Intestinal Submucosal Extracellular Matrix Patch in a Congenital Heart Program

BackgroundRepair of complex congenital heart disease frequently requires use of a patch as an anatomic substitute. The study’s aim is to evaluate the use, effectiveness, and safety of using small intestine submucosal extracellular matrix (SIS-ECM) patches in a congenital cardiac surgery program. MethodsThis is a single-center, retrospective, cohort study of surgeries using SIS-ECM between 2012 and 2019. The SIS-ECM data were categorized by use and type (four-ply and two-ply). All reinterventions and complications were reviewed by an independent surgeon, a practicing congenital heart surgeon, and a pediatric cardiologist. ResultsIn all, 408 SIS-ECM patches were used in 309 patients (188 male, 121 female; median age 8.5 months). Use of the patches consisted of 314 arterioplasties (77%), 22 venoplasties (5.4%), 63 intracardiac repairs (15.4%), and 9 valve repairs (2.2%). The most common use was for pulmonary artery repair (n = 181; 44.4%). Median follow-up time was 3.9 years (range, 3 days to 7.4 years). Ten patches (2.5%) required surgical reintervention (2 in the first 30 days and 5 in the first year) and 27 (6.6%) required percutaneous reinterventions (2 in the first 30 days and 22 in the first year). Between four-ply (n = 376) and two-ply (n = 32) SIS-ECM, the rate of surgical (2.1% [n = 8] vs 6.3% [n = 2], P = .18) or percutaneous reinterventions (6.4% [n = 24] vs 9.4% [n = 3], P = .46) was not different. There were no deaths related to the SIS-ECM patch or reports of calcification. ConclusionsThe SIS-ECM is a viable patch option that can be used in various cardiac and vascular reconstructive surgeries with low risk of failure and calcification. Long-term, positive outcomes may be maximized by using consistent techniques and understanding the appropriate applications of the patch.

Impact of unknown incidental findings in PET/CT examinations of patients with proven or suspected vascular graft or endograft infections

Vascular graft or endograft Infections (VGEI) are rare but severe complications of vascular reconstructive surgery, and associated with significant mortality and morbidity risk. Positron emission tomography/computed tomography with 18F-fluorodeoxyglucose (PET/CT) has been shown to have a high diagnostic accuracy in the detection of VGEI. In this single-center prospective cohort study, we assessed the rate and the impact on patient management of relevant unknown incidental findings in PET/CT of patients with proven or suspected VGEI, and clinical follow-up of all patients was performed. Our study results show a comparably high rate of relevant unknown incidental findings (181 in 502 examinations), with documented direct impact on patient management in 80 of 181 (44%) of all findings. PET/CT scan- and patient-based evaluation revealed impact on patient management in 76 of 502 (17%) of all PET/CT scans, and in 59 of 162 (36%) of all patients, respectively. Furthermore, PET/CT correctly identified the final diagnosis in 20 of 36 (56%) patients without VGEI. In conclusion, in proven and suspected VGEI, PET/CT detects a high rate of relevant unknown incidental findings with high impact on patient management.

Current trends in the creation of cell-free allo- and xenotissues for reconstruction of heart structures

Tissue engineering has significant potential for solving the problems of durability of biological tissues when used in cardiac and vascular reconstructive surgery. A decellularization technology has been proposed for obtaining a biomaterial, morphologically and functionally similar to the damaged human heart tissue. This review discusses various aspects and models of biological tissue decellularization, including the modern technology of using supercritical carbon dioxide as the most eco-friendly and promising method.

Treating a thrombotic giant dissecting renal artery aneurysm through ex-vivo vascular reconstructive surgery followed by kidney reimplantation

Renal artery aneurysms, although rare, may give rise to complications both per se (due to the risk of thrombosis and subsequent wall rupture) and by impairment of the renal function (due to extrinsic compression and high blood pressure). We describe a paucisymptomatic young patient with acute thrombosis of a massive dissecting renal artery aneurysm, for which the successful treatment was performed through ex-vivo vascular surgery followed by autotransplantation of the reconstructed kidney. The aneurysm was described through abdominal echography, computed tomography angiography, and transfemoral transcatheter arterial angiography. It originated from an atypical branch emerging at 90 degrees from the left renal artery. After a short branching off, it degenerated into a dissected aneurysmal sac as large as half a kidney (outer diameter of 60 mm), compressing the lower pole of the left kidney and delaying the lower half nephrogram. Ex-vivo surgical exclusion of the aneurysm was successfully performed. The kidney was reimplanted in the left iliac fossa (termino-lateral anastomosis between the renal artery and external left iliac artery, termino-terminal ureteric anastomosis) with excellent postoperative outcomes. For most asymptomatic aneurysms, expectant treatment is a reasonable approach. However, interventional or surgical repair is indicated in certain circumstances depending on the size of the aneurysm and its natural history, rupture risk, and interventional/surgical risks. The renovascular hypertension, dissecting and thrombotic events, its giant size, the young fertile age, and the presence of the flank pain were all indicative of the need for aneurysm exclusion in our case.

Complications Following Pre-Operative Radiotherapy and Vascular Reconstruction to the Groin in Sarcoma Patients: A Series of Cases

Background: The mainstay of therapy in most soft tissue sarcomas is a combination of surgery and radiotherapy. Although aimed directly at the tumor, radiotherapy may also cause damage to surrounding tissue, particularly at therapeutic levels. In most cases, irritated tissue will heal well, although some longlasting effects may remain. In patients presenting with large sarcomas near the groin, pre-operative radiotherapy followed by radical excision and vascular reconstruction is a common practice. However, neither synthetic vascular grafts nor venous autografts tend to react well to radiotherapy. Case Presentation: In this case series, we report 3 patients who underwent pre-operative radiotherapy prior to vascular reconstructive surgery. In all 3 cases, many post-operative complications necessitated multiple further operations. Two of the 3 eventually required an above and below knee amputation, and the third developed sepsis and pulmonary metastasis. We discuss the role of pre-operative radiotherapy and vascular reconstruction to the groin in sarcoma patients, and query whether this combination could be reconsidered given the potential consequences. We also discuss the efficacy of a lower therapeutic radiotherapy dose and the effect this may have on surgical outcomes. Conclusion: The combination of pre-operative radiotherapy and vascular reconstruction to the groin in sarcoma patients may carry significant morbidity, thereby putting the limb and/or life at risk. The need for pre-operative radiotherapy in groin sarcoma patients requiring vascular reconstruction should therefore be considered very carefully by an expert multidisciplinary team. Post-operative radiotherapy may be a suitable alternative.