Reverse Saphenous Vein Graft Research Articles

Management of lower extremity vascular injuries in pediatric trauma patients: 20-year experience at a level 1 trauma center

IntroductionPediatric lower extremity vascular injuries (LEVI) are rare but can result in significant morbidity. We aimed to describe our experience with these injuries, including associated injury patterns, diagnostic and therapeutic...

WTP1.12 Axillary Artery Aneurysm in a Patient of Achondroplasia

Abstract Background Axillary artery aneurysms are extremely rare mainly occurring as pseudo-aneurysms. They are most commonly caused by trauma however; fungal infections, atherosclerosis, connective tissue diseases, vasculitis and thoracic outlet syndrome are also among the etiological factors. Case Summary Seventeen years old, unmarried, achondroplasic (three feet height) girl presented to OPD with pulsatile swelling and pian in right axilla for six months. Pain was accompanied by weakness and numbness of hand. The swelling was initially small in size which increased over time. Patient had history of left axillary artery aneurysm back in 2015 for which left axillary repair was done. There was no history of axillary trauma. On physical examination an approximately 4×2 cm lump was palpable in right axilla. It was round in shape, mobile, pulsatile and non-expanding with no overlying skin changes. The patient had hypotonia with power of 3/5 in all limbs. Deep tendon reflexes were reduced. Rest of systemic examination was unremarkable. CT angiography was done which showed brachiocephalic trunck and right proximal subclavian artery normal. There was a lobulated enhancing area along the course of the Right axillary artery measuring 3.5×4.7×3.0 cm. The axillary artery aneurysm was excised and arterial continuity was restored by placement of Reverse Saphenous vein graft. Discussion The conventional method of axillary artery aneurysm repair is aneurysmectomy followed by placement of bypass graft. Owing to long term patency, saphenous vein graft serves as an ideal for reconstruction. Conclusion axillary artery aneurysms should be considered as a differential for pulsatile axillary swellings and should be promptly treated to avoid life threatening complications.

A Case of Traumatic Hand Ischemia – Managed Successfully with Neurovascular and Soft-tissue Reconstruction

Upper limb has rich vascular supply due to sufficient collaterals around the shoulder, elbow, and wrist joints which prevents ischemia and maintains viability of the upper limb in case of vascular injury or occlusion. There are numerous literature available, regarding the management of isolated single arterial injury in the forearm, which suggest that ligation of single artery (radial or ulnar) is safer if the companion arterial supply is intact. Hand salvage becomes more challenging when patient presents with acute hand ischemia following injury to both forearm arteries and has associated musculoskeletal injuries. We hereby report the case of a 24-year-old male who sustained glass-cut injuries to his right distal forearm resulting in both forearm arterial, nerves, flexor tendon injuries, and presented as acute hand ischemia. The patient was managed by reconstruction of radial and ulnar arteries using reverse saphenous vein graft (RSVG) along-with primary repair of median and ulnar nerves and flexor tendons. Skin and soft tissue defect was subsequently covered using antero-lateral thigh flap. The prompt and timely management of patient resulted in hand salvage with good functional outcome.

Ex vivo Repair of Renal Artery Branch Aneurysm in Fibromuscular Dysplasia

Renal artery aneurysm is a rare disorder with an incidence of < 1%. We describe a case of fibromuscular dysplasia with right renal artery branch aneurysm, who had uncontrolled renovascular hypertension. The patient was successfully managed with ex vivo repair and reconstruction of the renal artery using reverse saphenous vein graft, followed by autotransplantation of the right kidney. Although surgically demanding, the technique is feasible and yielded good results.

An outcome of emergency vascular surgery performed by general surgeons; our experience in a university hospital of Pakistan and can they substitute vascular surgeons?

To measure the outcome of emergency vascular surgery performed by general surgeons, and to identify preventable causes of mortality. The retrospective study was conducted at the General Surgery Department of Mayo Hospital, King Edward Medical University, Lahore, Pakistan, and comprised data between January 2014 and May 2019 related to cases regardless of age and gender that required emergency vascular surgery after diagnosis by a consultant surgeon at the surgical emergency. The cases were analysed from admission till discharge. Data was analysed using SPSS 20. Of the 135 cases, 127(94%) were males. The overall mean age was 28.8±11.5 years (range: 14-63 years). Mean duration of hospital stay was 11±3.92 days (range: 4-22 days). Three major peripheral arteries injured were brachial 32(38.5%), popliteal 55(40.7%) and femoral 20(20.7%), with more than half with complete transection 75(55.6%). Vascular repairs done were primary anastomosis 45(33.3%), reverse saphenous vein graft 68(50.4%), embolectomy 4(3%) and amputation 18(13.3%). Limb salvage rate and mortality was 101(74.8%) and 6(4.4%), respectively. Complications occurred in 38(28.1%) cases, with 24(18%) wound infections and 9(6.7%) myonecrosis. Factors leading to poor outcome/complications were Glasgow Coma Scale score <12 (p=0.01), referred case (p=0.04), significant bleeding (p=0.004), haemoglobin <9 at presentation (p=0.001), bone fracture (p=0.01), involvement of lower limb (p=0.003) and late presentation (p=0.003). Late presentation in hospital was the major modifiable factor improvement of which could lead to better outcome, apart from the early and proper surgical intervention.

Traumatic Axillary Artery Repair

Introduction: Only 15%–20% of the arterial injuries of the upper limbs are due traumatic axillary artery injury. Out of all ninety four percent are due to penetrating wounds, while the remaining 6% are caused by blunt traumas. Four cases with traumatic axillary artery injury are reported here. Materials and Methods: Four patients diagnosed with traumatic axillary artery injury underwent vascular repair presented between October 2019 and September 2020 are included in this study. Results: Fifty percent of patients presented with blunt trauma, whereas 50% with penetrating injury. Only one patient had associated bone injury. Hundred per cent of the patients had absent peripheral pulsation, while 50% of patients presented with warm upper extremity and normal capillary refill time. Seventy-five percent of patients involved had trauma to 1st part of axillary artery, whereas one patient suffered trauma to 2nd part. Two incisions, i.e. supraclavicular and infraclavicular incisions were taken to take proximal control of subclavian artery in two patients with trauma to 1st part of axillary artery. Only one patient underwent vascular repair with reverse saphenous vein graft, rest all patients underwent end-to-end axillary artery repair. Twenty-five percent of patients had associated brachial plexus injury and bone injury, respectively, which were taken care off along arterial repair. Hundred percent of the patients had good vascular outcome postoperatively. Conclusion: Patients presenting with trauma to periclavicular region must be thoroughly examined for associated axillary artery injury and if diagnosed with same must undergo prompt surgical exploration and arterial repair. For good proximal control, it is advisable to go for both supraclavicular and infraclavicular incisions in case of injury to 1st part of axillary artery.

Use of Medial Gastrocnemius Muscle Flap in Traumatic Popliteal Artery Injury Due to Posterior Dislocation of Knee Joint

Introduction: Injury to the popliteal region affects vascularity and soft tissue necrosis. The purpose of the study is to use the medial gastrocnemius muscle flap to enhance the soft tissue cover of the injured area. Materials and Methods: This retrospective study was conducted in the Department of Plastic surgery from January 2019 to December 2020. All patients admitted under the department with posterior dislocation of the knee with vascular compromise to the limb were enrolled in the study. Results: Five patients were included in the study. In all the five cases, the limb was salvaged with reverse saphenous vein graft harvested from the thigh region of the opposite limb with soft tissue cover of medial gastrocnemius muscle flap. Postoperative limb movements were satisfactory. The average duration of hospital stay was approximately 21 days. Conclusion: Usage of medial gastrocnemius flap serves an adequate soft tissue coverage in traumatic popliteal artery injury

Asymptomatic vascular lesion due to a firearm projectile of the right arm of 30 days of evolution. Case report

A 27-year-old male patient presenting a gunshot wound in the right arm with slight paraesthesia in the tips of his fingers. Patient was referred to the orthopedic unit to undergo bone fixation due to a fracture of the right radius, with absent distal pulses. He also presented vascular compromise. An arteriography was requested that showed vascular injury of the humeral artery. A reverse saphenous vein graft was placed. The patient had good evolution with normal pulses

Retrograde Mesenteric Bypass with Saphenous Vein Graft in Chronic Mesenteric Ischemia in a Resource-Challenged Setting

Introduction: Chronic mesenteric ischemia is a pathophysiologic condition arising due to demand–supply mismatch of blood supply to bowel postprandially, resulting in chronic abdominal pain, food fear, and weight loss. The most common cause is atherosclerosis. Timely intervention in the form of mesenteric revascularization is the key to successful outcome. There are limited contemporary data on in-hospital outcomes of mesenteric revascularization via open versus endovascular therapy in a resource-challenged setting. Materials and Methods: This retrospective-prospective observational study included eight patients of chronic mesenteric ischemia who underwent open revascularization and were followed for a mean duration of 15 months. All patients were evaluated as per the institutional protocol, and retrograde mesenteric bypass with reverse saphenous vein graft was done in all cases. Outcomes were evaluated in terms of resolution of symptoms and confirmation of graft patency with duplex scan after 1 month and every 6 months thereafter. Results: Out of 8 patients, six patients were males. Predisposing factors for atheromatous diseases were present in all. All patients presented with postprandial abdominal pain and weight loss. Majority of patients (n = 5) had involvement of all three mesenteric vessels (superior mesenteric artery, inferior mesenteric artery, and celiac axis). One patient was re-explored for bleeding in immediate postoperative period. One patient was admitted for small bowel obstruction in 1st month of follow-up after surgery and was managed conservatively. Two patients were lost to follow-up and six patients are symptom free and doing well on a close follow-up of 15 months. Conclusion: Open mesenteric revascularization, by reverse saphenous vein graft as conduit for bypass, performed by experienced surgeon gives promising results in terms of symptom-free duration and graft patency and can be preferred over endoscopic revascularization as a viable option in resource-challenged settings in developing nations.

Surgical Outcome of Peripheral Vascular Injuries in Adults.

To describe the management and outcome of adult patients after peripheral vascular injuries. Observational study. Accident & Emergency Department, Mayo Hospital Lahore, Pakistan, from January 2014 to December 2018. All adult trauma patients (aged ≥13 years), who were admitted following injury to peripheral blood vessels regardless injuries, were included. Variables including patient data, mechanism of injury, vessel involved, injury severity score (ISS), surgical procedure etc. were retrospectively extracted from patient charts. Binary logistic and multinomial regression analyses were performed. The p-value <0.05 was considered significant for mortality and limb outcome. There were 117 patients, with mean age of 28.9±11.6 years. The commonest cause was blunt trauma (55.6%). The popliteal artery was most commonly involved (44.4%). Complete transection of artery was the most common type of injury (58.1%). The mean ISS was 17.2 ± 10. Reverse saphenous vein graft (RSVG) was the most common surgical repair (49.6%) procedure. Wound infection (17.1%) was the main complication. Limb salvage rate was 73.5% and mortality rate was 5.1%. Variables significantly influencing the limb outcome (amputated vs. salvaged) were duration of injury (p <0.001), concomitant body injury (p=0.009), ISS (p <0.001), surgical procedure (p <0.001), hemoglobin on presentation (p<0.001), number of blood transfusion (p=0.05) complications after surgery (p <0.001) and referral or not (p=0.001). Factors significantly associated with mortality were duration of injury (p=0.008), ISS (p = 0.002) and complications after surgery (p=0.011). Low hemoglobin on presentation, postoperative increased requirement of blood transfusions and having reverse saphenous graft as procedure were independent risk factors for amputation. ISS score and postoperative complications led to higher amputation and mortality rates after surgery. Key Words: Injury severity score (ISS), Glasgow coma scale (GCS), Reverse saphenous graft (RSVG), Fasciotomy, Popliteal artery, Mortality.

A Challenging Surgical Case of Axillary Artery Pseudoaneurysm Weeks after Blunt Trauma

Axillary artery injury is a rare complication of blunt upper extremity trauma and is reported in the literature on only a few cases. The usual treatment is an open operation with the exclusion of the aneurysm and interposition grafting. Vascular injury in the elderly population after trauma is especially “dangerous” owing to a large cohort of these patients being on anticoagulation. For this reason, any hematoma after blunt trauma must be fully “evaluated” and a careful vascular exam must be undertaken. When the vascular injury is acute as a result of trauma, the typical interventions include an open repair either with an interposition graft or reverse saphenous vein graft. We report a case of a delayed traumatic axillary artery dissection with resultant pseudoaneurysm treated with endovascular stent-grafting.

Open surgical reconstruction of the extracranial internal carotid artery aneurysm at the base of the skull: An experience of five cases in a tertiary vascular surgery center

Aim: Aneurysms of the internal carotid artery (ICA) at the base of the skull are uncommon dangerous lesions whose management remains unclear. The aim of this retrospective study is to report the short term results of open surgical repair done in our center to formulate a standardized surgical technique of ICA reconstruction with best results. Subjects and Methods: From 2017 to 2019, totally five ICA reconstructions were performed for extracranial internal carotid artery (EICA): two male patients and three female patients (mean age, 34 years). The cause was atherosclerosis (n = 3 patients), trauma (n = 1 patient), and syndromic (associated with a complex congenital cardiac condition, n = 1 patient). The symptoms were mainly swelling and pain, in one case. Results: All patients underwent open extracranial surgical reconstruction at the skull base; interposition grafting using reverse saphenous vein graft was used in three cases, after resection of the aneurysm, and direct end to end anastomosis was employed in two cases of saccular aneurysms. The ICA was patent on the postoperative angiogram in all cases. All patients are doing well on follow-up. Conclusion: Venous graft bypass and direct ICA to ICA anastomosis for EICA can be performed safely with an open surgical approach and produces durable satisfactory results.

A rare case of symptomatic true aneurysm of posterior tibial artery

Aneurysms of the infrapopliteal region are uncommon. Of them, true aneurysms are very rare and that of the posterior tibial artery (PTA) are extremely rare. We present a case of a 25-year-old female presented with a pulsatile mass behind the right medial malleolus for 1-year duration. Arterial duplex and angiogram revealed a true saccular aneurysm of the PTA. The aneurysm was resected, and the PTA was reconstructed with a reverse saphenous vein graft.

Management of vascular injury in counter insurgency area: A single-center study

Background: Vascular trauma can threaten both limb as well as life of the patient. Combat-related vascular injuries are different from civilian vascular injuries in terms of epidemiology, mechanism, pathophysiology, and outcome. Combat or military trauma is generally penetrating trauma (high energy weapons). Difficult evacuation and transportation from the battle field complicates the vascular injury and its outcome. Materials and Methods: This is a single-center, prospective, observational study conducted at a service hospital in Jammu and Kashmir. Twenty-five patients with mean age 25.76 years (18–43 years) who underwent vascular intervention for trauma from December 2013 to November 2016 were included. Data pertaining to vascular injury regarding to site of injury, associated injuries, type of vascular repair, outcome, and complications were recorded and analyzed. Results: Five hundred and eighty trauma patients were admitted during the study period with 4.3% of the patients having vascular injury. All the patients were males and most of them were in the second or third decade of life. The mean time interval between the trauma and arrival to the hospital was 7 h. Lower extremity was the most common site of trauma (52%) of the patients followed by upper extremity. In 56% of the patients, vessels were repaired with reverse saphenous vein graft harvested from the uninjured limb. Two patients (8%) had secondary amputation and one patient (4%) died due to sepsis. Conclusion: Expeditious evacuation, quick transfer, early diagnosis and management including advanced endovascular care are essential for the limb salvage and survival of the serving soldiers.

Wewnątrznaczyniowe zamknięcie pękniętego tętniaka przeszczepu z odwróconej żyły odpiszczelowej w poddanej zabiegowi naprawczemu przetoce tętniczo-żylnej — kwestie techniczne

A 49-year-old diabetic woman who had end stage renal disease associated with membranous glomerulonephritis, was undergoing dialysis through a left brachiocephalic arteriovenous fistula. After sometime, fistula became infected and stopped functioning. It was closed and arterial segment was resected and repaired with reverse saphenous vein graft. After 6 months interval, she presented with painful, expansile swelling with intermittent bleeding. Arteriogram showed ruptured aneurysm of reverse saphenous vein graft with a proximal venous stenosis. It was successfully closed with 6 × 60 mm Fluency Plus self-expanding vascular stent graft (Bard, Tempe, AZ) with resolution of her symptoms.

Coinciding anomalous coronary artery and papillary fibroelastoma.

Introduction: The primary cardiac tumors are extremely rare tumors that arise from the normal tissues that make up the heart. Those tumor can be divided into Benign, mostly myxoma or malignant tumors. Fibroelastoma are rare benign tumors of the endocardium. They are usually left sided, with few cases reported of pulmonary valve papillary fibroelastoma. No case of fibroelastoma and anamolous coronary artery. Case Presentation: 61 year old female with past medical history of diabetes mellitus was complaining of chronic stable angina. Admitted after an outpatient positive treadmill EKG test (ST segment depression inferiolaterally). Final/Working Diagnosis: Left heart cath demonstrated angiographically normal coronaries with an anomalous left main coronary artery originating from the right coronary cusp with no significant disease. Management: CT angiogram similarly demonstrated an anomalous origin of the left main coronary artery from a common ostium with the right coronary artery originating from the right sinus of Valsalva. The left main coronary courses between the aorta and right pulmonary outflow tract consistent with an intra-arterial course.Echo showed an incidental finding of a mobile structures attached to the pulmonic valve, 0.7x0.7 cm in size, whose appearance was consistent with papillary fibroelastoma . CardioThoracic surgery was consulted for patient continuous angina symptoms not responsive to medical therapy and the above coronary artery findings, it was believed that she would not benefit from relocation of the left main coronary artery due to the common ostia with the right and its intra-arterial course. Patient had 2 vessel coronary artery revascularization (LIMA to LAD, reverse saphenous vein graft to ramus with endoscopic vein harvest and excision of pulmonary valve mass). The pathology report confirmed the diagnosis of papillary fibroelastoma. Disclosure Saif Ibrahim, MD – No Relevant Financial Relationships to Disclose Steven Lavine, MD – No Relevant Financial Relationships to Disclose Jean Touchan, MD – No Relevant Financial Relationships to Disclose

Patency of Reverse Saphenous Vein Graft for Revascularization of Lower Limbs in Diabetic Patients

Objectives: Diabetic patients are prone to early development of vasculopathy, resulting in lower limb ischemia, which can lead to non-healing ulcers, foot infection, loss of limb, and even death. These patients need revascularization of their limb either using endovascular or open surgical techniques. Not all patients are suitable for endovascular treatment warranting the open surgical revascularization techniques.

Surgical techniques for hemostasis in penetrating trauma to femoral artery

Objectives: To analyse the efficacy of various operative procedures and factors affecting the outcome especially the effect of limb ischemia time in penetrating trauma to the femoral artery. Study Design: Prospective. Setting: Study was conducted at West Surgical Ward, Mayo Hospital Lahore. Duration: August 2001 to July 2004. Materials and Methods: All the patients &gt;12 years of age referred from periphery as well as directly admitted with penetrating trauma to the femoral vessels alone or associated with other organ injuries having hard/soft physical signs of an arterial injury were included in the study. Results: 39(97.5%) patients were male, age ranged from 14-53 years with the mean limb ischemia time of 7.8 hours in the series. 35(87.5%) patients sustained firearm injuries. Superficial femoral artery was injured in 23(57.5%) followed by vein in 12(30%) and major vessels were found intact in 4(10%) patients. Lateral arteriorrhaphy was performed in 4(10%) &amp; venorrhaphy in 3(7.5%) patients with 100 % succ ess rate, resection and primary anastomosis in 18(45%) patients with pseudo aneurysm formation in 1(2.5%) patient. Reverse great saphenous vein graft was interposed in 9(22.5%) patients with graft failure rate of 5% (2 patients). Femoral vein was ligated in 12(30%) patients with development of deep vein thrombosis in 2(5%) patients. There were 3(7.5%) deaths. No synthetic graft was used in the series. Conclusion: Exsanguination, prolonged injury duration, associated organ injuries and extensive soft tissue and skin damage of the extremities were the major factors responsible for increased morbidity particularly limb loss and mortality. Proximity of injury to the femoral vessels was a poor predictor of an arterial injury in the study. Arteriorrhaphy and primary end-to-end anastomosis are the main stays for an arterial injury repair, next comes the use of autogenous vein graft, in our setup. Moreover ligation of femoral vein is not associated with leg amputation.

Brachial artery injury management: Case series

We performed this retrospective study to analyze our strategies for managing and surgically treating brachial artery injuries. Twenty patients with traumatic brachial artery injuries underwent surgery at our institution, from May 2013 to January 2016. Fifteen patients were male, and five were female (age range, 20-45 years; mean, 30 years). Twelve of the patients had penetrating injuries (two had stab wounds; two had window glass injuries; and eight had industrial accidents); eight had blunt trauma injuries (traffic accidents). Five patients had a peripheral nerve injury. All patients underwent Doppler ultrasonographic examination. The repair involved end-to-end anastomosis for eight injuries, reverse saphenous vein graft interpositional grafts for eight, and primary repair for four. Venous continuity was achieved in 8 of 12 patients who had major venous injuries. Nine of the twenty patients required primary fasciotomy. Follow-up showed that two of the five patients with peripheral nerve injury had apparent disabilities due to nerve injury. There were no deaths. Good results can be achieved in patients with brachial artery injuries by use of careful physical examination, Doppler ultrasonography, and vascular repair and debridement of nonviable tissues. Traumatic neurologic injury addressed expediently with nerve grafting may reduce the subsequent disability.

The vastus lateralis free flap for lower extremity gustilo grade III reconstruction.

Orthopedic trauma patients with Gustilo grade III injuries to the distal third of lower extremity present challenges to optimum reconstructive management. There is no consensus on the ideal autologous tissue for transfer in large lower extremity defect reconstruction. We present a large case series utilizing the vastus lateralis (VL) free flap for lower extremity Gustilo grade III reconstruction. This is a case series of patients who underwent VL free tissue transfer for Gustilo grade III injuries. A total of 38 free tissue transfers were performed for lower extremity reconstruction, 19 of which were VL flaps. Mean interval between injury and reconstruction was 46 days (range 7-240 days). The mean wound size was 11.37 cm x 11.42 cm and all cases underwent delayed reconstruction. Seven day flap viability was 100% and 30-day flap viability was 17/19 (89%). There were six complications: two hematomas requiring drainage, one flap dehiscence, one distal flap loss requiring a reverse saphenous vein graft extension, and two complete flap losses. Of the two failed flaps, one was attributed to heparin-induced thrombocytopenia and the other to venous congestion complicated by methicillin-resistant Staphylococcus aureus infection. The VL free flap is a reliable and versatile flap that can be tailored and tangentially thinned to match the shape and size of a defect, and the long pedicle allows the surgeon to stay away from the zone of injury. This flap should be strongly considered for lower extremity reconstruction, especially in salvage operations for large defects. © 2015 Wiley Periodicals, Inc. Microsurgery 37:212-217, 2017.