Site Of Proximal Anastomosis Research Articles

Concomitant bilateral popliteal arterial aneurysm and abdominal aortic aneurysm in a case with severe occlusive disease of lower extremity

Methods Our case was a 53-year-old male. He was presented to our surgical council after detailed investigations carried out at another institution.His past medical history was significant for left infragenual femoropopliteal bypass using PTFE graft 2 years ago. He was complaining from claudication of his left lower extremity at a walking distance of 100 m. Results Color Doppler ultrasound revealed bilateral popliteal arterial aneurysm of 2-2.5 cm. Computed tomographic angiography showed a fusiform aneurysmal dilation of the abdominal aorta with a largest diameter of 38 mm. Left superficial femoral artery was totally occluded and the graft was patent. There was a high-grade stenosis at the site of proximal anastomosis. Both popliteal arteries showed aneurysmal dilation of 35 and 25 mm, right and left sides, respectively. Right peroneal artery was patent but the remaining two branches were perfused via collaterals. All of the 3 infragenual branches were patent on left with occlusion of the anterior tibial artery distally. Pedal arteries were patent. Coronary angiogram discovered some non-significant stenotic lesions at left anterior descending and right coronary arteries. With these findings, we planned percutaneous balloon dilation or, if necessary, stenting of the proximal anastomosis site and endovascular stent grafting of both popliteal arteries. He preferred to remain in outpatient follow-up. Conclusions Popliteal arterial aneurysms may be seen bilaterally and coexistent abdominal aortic aneurysm may be detected in 50% of cases. The priority in the treatment of the aneurysm includes prevention of limb ischemia or limb loss. In addition to the open surgical approach, endovascular stent grafting gains popularity and becomes a widely performed application.

Radial artery for coronary artery bypass grafting: does proximal anastomosis to the aorta or left internal mammary artery achieve better patency?: Table 1:

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'in coronary artery bypass grafting using radial artery grafts, does proximal anastomosis to the aorta or left internal mammary artery achieve better patency'. Altogether >183 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Radial artery grafts typically have a narrower lumen than vein grafts, and as such there is some concern that anastomosing them directly to the aorta during coronary artery bypass grafting (CABG) may impair graft patency. As such, some surgeons prefer to anastomose radial artery grafts to a second-order vessel such as the left internal mammary artery (LIMA). We sought to assess the evidence for this. A handful of papers directly addressing the issue of the effect of the site of proximal anastomosis on graft patency were found, with three showing no significant difference. One such study reported an insignificant difference in angiographic patency at 32 months postoperatively, with 94.1% of off-aorta grafts remaining patent vs 87.2% of off-LIMA grafts (p = 0.123). However, a large-scale well-designed study was able to demonstrate a statistically significant difference at five years postoperatively, with 74.3% of off-aorta grafts patent, compared with 65.2% of off-LIMA (p = 0.004). Nonetheless, a number of papers that report patency for either off-aorta or off-LIMA grafts give comparable figures for each technique. Additionally, different centres and investigators report very different patency results for grafts that have the same site of proximal anastomosis. One centre was able to achieve patency rates for off-LIMA grafts of 88% up to a mean of 7.7 years postoperatively while another centre reported a patency rate of only 78.6% at three years. Given this, and the plethora of other factors influencing graft patency, we conclude that the best evidence suggests that the site of proximal anastomosis has little or no effect on radial artery graft patency following CABG.

Circumaortic Left Renal Vein Associated with Juxtarenal Abdominal Aortic Aneurysm

The patient was an 82-year-old man who was found to have a juxtarenal abdominal aortic aneurysm accompanied by a circumaortic left renal vein (CLRV). During dissection of the proximal anastomosis site the CLRV was injured, but was successfully repaired. A graft implantation was performed below the renal arteries. The incidence of CLRV is thought to be rare, however it is found in 7% of cadavers donated for anatomy. CLRV may cause unexpected bleeding by inadvertent dissection of the abdominal aorta. To prevent unexpected bleeding, surgeons should always keep in mind this potential risk when performing surgery.

Extensive aortic prosthesis dilatation

Figure 1: A CT scan 2 years (A) and 14 years (B) after the initial aortic repair. It shows the enlarged prosthesis diameter of 42 mm (black dotted arrows), which has remained stable over time. Compared with the original dimension, the cross-sectional area of the prosthesis increased by 96%, and the prosthesis wall tension by 40%. Figure 2: Reconstructed three-dimensional angiography demonstrating the enlarged aortic prosthesis compared with the aortic root and the proximal aortic arch. White arrows mark the proximal and distal anastomosis site.

Severe Limb Ischemia Related to Previous Abdominal Aortic Aneurysm Repair Induced by Acute Aortic Dissection

We described the first case of limb ischemia induced by acute aortic dissection in the patient with previous abdominal aortic aneurysm (AAA) repair. A 56-year-old male was referred for severe limb ischemia. He underwent AAA repair one month before the referral. Computed tomography (CT) scan revealed Stanford type B aortic dissection extended to the proximal anastomosis site of the AAA repair. The false lumen made the complete interruption of antegrade blood flow at the proximal anastomosis site of the AAA repair.

Comparison of Different Methods of Aortic Valve Conduit Xenograft Preservation in an Animal Experiment Model; Fresh Cryopreservation versus Acellularized Cryopreservation

Background: The commercially used vascular xenografts have some problems such as calcification, fibrosis and tissue degeneration that are associated with inflammatory and immunologic reactions. We compared two methods of xenograft preservation (fresh cryopreservation versus acellularized cryopreservation) of goat aorta. Material and Method: Aortic valved xenografts were harvested from adult pigs, and these were preserved using fresh cryopreservation (FC group, n=4) or acellularized crypreservation (AC group, n=4). These xenografts were implanted into adult goats. There were 2 short-term survivors (less than 100 days) and 2 long-term survivors in each group. These xenografts were explanted and they underwent microscopic examination. Result: The goats survived 31, 40, 107 and 411 days in the FC group and the other goats survived 5, 40, 363 and 636 days in the AC group. All the short-term survivors in each group expired because of rupture at the proximal anastomosis site. Marked neutrophil infiltration was observed in the FC group FC and lymphocytes were observed in the AC group. There were no differences in the occurrence of calcification, fibrosis and thrombosis among the groups. Conclusion: Some goats survived more than 100 days after the xenograft implantation irrespective of the methods of preservation. Because severe tissue degeneration developed in both groups, we think these methods are not appropriate for xenograft preservation of aorta. It was worth a preliminary trial for improving the preservation method or to modify the processing of xenografts.

Foldback technique for aortic anastomosis of free right internal thoracic artery in coronary artery bypass grafting

We herein report a new technique that we term "foldback plasty" for stenosis-free proximal anastomosis of free arterial grafts without using any other interposition materials. The arterial graft is first anastomosed to the aorta in side-to-side fashion, leaving 1 cm of remnant tissue at the proximal end. The reverse side of the graft is then opened longitudinally, starting at the proximal end, to just distal to the aortic anastomosis site. The new proximal graft flap is folded back and sutured onto the graft to close the longitudinal opening. The proximal anastomosis site is enlarged only by the graft tissue, and stenosis can be avoided even if the graft has a small caliber.

P-139 Comparison of Radial Artery Patency According to Proximal Anastomosis Site: Direct Versus Composite Grafting

Results: Significant (P< 0.05) improvement of EF (from 27% to 36% in group A, from 23% to 36% in group B) and LVESVI (from 83ml/m2 to 63ml/m2 and from 112ml/m2 to 60ml/m2, respectively) was observed at 6 months. Hospital death due to ventricular tachycardia occurred in one patient in group A, and late cardiac death due to heart failure occurred in two patients in group B. Of 38 survivors at 6 months, all patients in group A and 95% of those in group B showed NYHA functional class I or II, whereas preoperatively 73% and 76%, respectively, showed NYHA functional class III or IV. Conclusions: LEMRI is a promising tool for selecting patients and areas for SVR, providing excellent clinical outcomes.

Revascularização miocárdica com artéria radial: influência da anastomose proximal na oclusão a médio e longo prazo

To determine whether the proximal anastomosis interferes or not in mid- and long-term patency of these grafts. One hundred twenty-three out of 481 patients who had undergone surgery using radial artery (RA) were restudied. The mean age was 58.8 + 10.4 years. In 96 (78.05%) patients the cardiopulmonary bypass (CPB) was used. Considering all surgical grafts, 382 coronary branches were grafted (mean, 3.1 + 0.8 arteries per patient). 150 of them used radial artery (RA), and the left marginal branches (LOM) were the most prevalent (48.67%). The proximal anastomosis was performed in the aorta in 50 (40.65%) patients and as an artificial 'Y' composite graft with the left or right internal thoracic artery (LIMA/RITA) in 73 (59.35%). Postoperatively, coronary angiography studies were performed within a mean period of 5.36 + 3.21 years. The obtained data was divided into two categories: proximal anastomosis (aorta/composite) and patency (occluded/patent). A chi-square test was used to compare both proportions, within a 95% confidence interval (CI). From the 50 aorta-anastomosed grafts, 42 (84%) were patent and eight (16%) occluded. Regarding the 73 'Y' composite grafts, 59 (80.82%) were patent and 14 (19.18%) occluded. Comparing these proportions in both techniques, there was no statistically significant difference between them (P=0.651, CI=95%). The site of proximal anastomosis of the RA coronary grafts does not interfere in mid- and long-term graft occlusion and patency.

Comparison of radial artery patency according to proximal anastomosis site: Direct aorta to radial artery anastomosis is superior to radial artery composite grafting

The radial artery is frequently the second graft of choice after the left internal thoracic artery in coronary artery bypass graft surgery. However, the optimal radial artery proximal anastomosis site remains controversial. The aim of the present study was to compare the radial artery patency according to its use as either an aorta-radial artery graft or composite radial artery graft in coronary artery bypass grafting. A total of 1735 patients received coronary artery bypass grafting using the radial artery between January 2001 and July 2007, of whom 893 received serial computed tomographic coronary angiographies; these patients formed the basis of the current study. The patients were divided into 2 groups: group I (direct radial artery to aortic anastomosis, n = 451 patients) and group II (radial artery composite grafting with the left internal thoracic artery, n = 442 patients). The number of distal radial artery anastomoses performed in group I was 657 and 749 in group II. Sequential bypassing was performed in 399 patients. The early patency rate was significantly higher in group I than in group II (98.3% vs 94.5%; P = .004). The 1-, 2-, and 5-year patency rates were also higher in group I than in group II (93.8% +/- 1.2%, 90.5% +/- 1.6%, and 74.3% +/- 6.1%, vs 90.5% +/- 1.4%, 85.3% +/- 1.9%, and 65.2% +/- 4.2%, respectively; P = .004). Multivariate analysis showed composite grafting (P = .02), the degree of target vessel stenosis <90% (P = .001), and the target revascularization site (P = .005) to be significant risk factors for occlusion. The results of the current data showed superior early and late patency rates of coronary artery bypass grafting with radial artery to aorta anastomosis compared with left internal thoracic artery-radial artery composite grafting.

Abstract 2559: Reflectance, Fluorescence, and Raman Spectroscopy Identify Features of Vulnerable Atherosclerotic Plaque In Vivo Including a Thin Fibrous Cap, Necrotic Core or Superficial Foam Cells, and Thrombus

Early detection and treatment of vulnerable atherosclerotic plaques, the lesions most prone to rupture, is critical to reducing patient mortality associated with cardiovascular disease. The combination of reflectance, fluorescence, and Raman spectroscopy - termed multimodal spectroscopy (MMS) - provides complementary and depth-sensitive information about tissue composition. We assessed the hypothesis that MMS can detect morphological features of vulnerable plaque: thin fibrous cap (TFC), necrotic core (NC), superficial foam cells (SFC), intralesional hemorrhage (IH), and thrombus. Methods. In vivo and ex vivo MMS spectra were collected from 12 patients undergoing peripheral vascular surgeries. The data collection was facilitated by means of a novel MMS probe catheter and a portable clinical instrument developed in our laboratory. During carotid endarterectomies, MMS spectra were collected in vivo from the intimal surface of the plaque with the probe held normal to the artery wall. During femoral bypasses, MMS spectra were collected in vivo either through the proximal anastomosis site from the posterior artery wall or adjacent to the incision. A tissue specimen was excised for additional MMS spectral collection ex vivo. Histopathological analysis was performed by a blinded cardiovascular pathologist to assess the vulnerability of each spectrally evaluated tissue site using a quantitative index based on the dimension or severity of the following: TFC, NC, SFC, IH, and thrombus. Across the total set of 76 evaluated tissue locations, MMS is shown to have the ability to detect vulnerability features including a TFC, NC or SFCs, and thrombus. A TFC is detected by measuring the relative amount of collagen assessed by fluorescence, a large NC or SFCs are detected through the combination of beta-carotene absorption and the Raman spectral signature of lipids, and thrombus is detected through its Raman signature. The results indicate that rupture-prone vulnerable plaques could be detected with a sensitivity of 96% and specificity of 72%. In conclusion, these encouraging results will help bring MMS into the clinical arena as a powerful, catheter-based diagnostic technique for early detection of vulnerable plaques.

A Simple Method of Inspection of Proximal Bleeding in Bentall Procedure

A simple method of checking for bleeding from the proximal anastomosis site in Bentall operations is described. After suturing a Carbo-Seal prosthesis to the aortic annulus, using a folding-over technique, the left ventricle is filled with cardioplegic solution through the prosthetic valve, and the heart is massaged to visualize possible leaks at the level of the suture.

Arterial coronary–coronary conduit over single, distal left anterior descending coronary artery lesion: 3.5 years afterward

Arterial coronary–coronary conduit over single, distal left anterior descending coronary artery lesion: 3.5 years afterward

Portal Vein Interposition Using Homologous Iliac Vein Graft during Extensive Resection for Hilar Bile Duct Cancer

Although autologous vein grafts have been used for portal vein (PV) reconstruction after long-segment portal vein resection during surgery for hilar bile duct cancer, their procurement prolongs operation time and increases morbidity. Less is known regarding the use of homologous vein grafts. The feasibility of homografts for PV reconstruction was preliminarily evaluated in two patients who underwent curative resection for hilar cholangiocarcinoma. Both patients underwent left lobectomy, caudate lobectomy, bile duct resection, and segmental PV resection and interposition vein graft reconstruction. The iliac vein homografts were obtained from deceased organ donors and stored for 1–2 days in cold preservation solution without freezing. Neither immunosuppression nor anticoagulation was attempted. One patient has shown good PV patency for 27 months. The second patient, who had received adjuvant chemoradiotherapy, showed an asymptomatic waisting at the proximal PV anastomosis site after 4 months, which was relieved by percutaneous balloon dilatation, and has been doing well for 12 months. In conclusion, our preliminary experience with these two patients suggests that cold-stored iliac vein homografts can be considered as PV substitutes after long PV segment resection during extensive hepatobiliary surgery.

Double-Outlet Left Ventricle

A newborn male was transferred for severe cyanosis and suspected transposition of the great arteries and ventricular septal defect (VSD). An emergency balloon septostomy was performed. The position and commitment of VSD and great arteries were more precisely defined by echocardiography. There was double-outlet left ventricle (DOLV) with doubly committed VSD, l-malposition of the great arteries, and pulmonary stenosis. The infundibular septum was virtually absent. A modified Blalock–Taussig shunt was inserted before a Rastelli-type corrective surgery was performed at 20 months of age. The VSD was closed, the pulmonary trunk was transsected, …

Use of Intraoperative Epiaortic Ultrasonography To Delineate Aortic Atheroma

A cerebrovascular accident (CVA) is a devastating complication of coronary artery bypass grafting (CABG) and a major cause for morbidity and mortality. Aortic manipulation, cannulation, and clamping during CABG may lead to release of atheromatous material from the ascending aorta, which may cause a CVA. This study assessed the hypothesis that the use of intraoperative epiaortic ultrasonography (EAUS) would supplement imaging information with that derived from manual aortic palpation and influence the surgical decision-making approach accordingly. After undergoing a mid-sternotomy for CABG, 105 patients underwent EAUS with an 8-MHz transducer ordinarily used for conventional transthoracic echocardiography. The surgical strategy was decided on at three stages: preoperatively, after manual aortic palpation, and following EAUS. The preoperative strategy had assigned 105 patients to the "touched aorta" group that was planned for either on-pump or off-pump CABG (OPCAB) with proximal anastomosis to the aorta. Pathologic lesions of the atheromatotic ascending aorta were evident in 40 patients (38%), with the lesions detected in 22 patients (21%) by both palpation and EAUS, and in 18 patients (17%) by EAUS alone. The planned surgical strategy was changed in 29 patients (28%): 25 patients (24%) were converted from on-pump CABG to OPCAB, and the EAUS influenced the choice of the aortic cannulation, cross-clamping, and proximal anastomosis site in 4 patients (4%). Among the changes in surgical decision making, changes in 11 patients (10%) were based on lesion detection by both manual palpation and EAUS; in 18 patients (17%), changes resulted from pathologic evidence provided by EAUS alone. This study showed EAUS to be more sensitive in detecting atherosclerotic lesions than manual intraoperative palpation of the ascending aorta. This investigation contributes new data on the effect of EAUS on intraoperative surgical approach in the era of OPCAB. The use of EAUS has emerged as an important tool in intraoperative decision making, and we recommend its use routinely in CABG procedures.

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The Right Internal Thoracic Artery and Right Gastroepiploic Artery: Alternative Sites for Proximal Anastomosis in Patients with Atherosclerotic Calcified Aorta

Atherosclerotic or calcified ascending aorta is an important predictor of adverse cerebrovascular events. Using off-pump coronary artery bypass (OPCAB) with composite and in situ arterial grafting to avoid aortic manipulation and clamping may reduce the risk of stroke related to aortic atheroembolism. When the aorta is calcified and cannot serve as a safe site for proximal anastomosis, this anastomosis can be performed on the proximal segment of the right internal thoracic artery (ITA) and right gastroepiploic artery (RGEA). Four such cases are described. In 2 patients, the proximal right ITA was used as the site for proximal saphenous vein graft (SVG) anastomosis. Chronic obstructive lung disease in one patient and insulin-dependent diabetes in the other precluded performance of OPCAB with bilateral ITA. In addition, positive Allen test precluded performance of composite T-graft with radial artery (RA) on ITA. Both SVGs were anastomosed distally to the posterior descending artery. In 2 other patients, RA was connected end-to-side to the proximal segment of the RGEA. Both of these patients had repeat operations. The distal end of the RGEA was too small, and concerns regarding the future flow to a very large coronary bed precluded its use as an in situ graft. All patients underwent the operative procedures without any neurological or cardiovascular adverse effects, and all are midterm, symptom-free survivors. Postoperative graft patency was confirmed intraoperatively with flow measurements and postoperatively with control angiography or coronary imaging computed tomography. The RITA and proximal RGEA can serve safely as sites for proximal anastomosis in patients with atherosclerotic calcified aorta undergoing OPCAB.

Total Arterial Revascularization for Multiple Vessel Coronary Artery Disease: With or without Cardiopulmonary Bypass

To assess the usefulness of off-pump technique for more technically demanding coronary artery bypass procedures using exclusively arterial conduits. Analysis of perioperative data of 324 consecutive patients in whom total arterial revascularization for multiple- vessel coronary artery disease was performed--181 cases on-pump and 143 cases off-pump. On average in the on-pump group 2.7 +/- 0.8 (range, 2-5) grafts per patient were constructed versus 2.4 +/- 0.7 (range, 2-4) grafts per patient in the off-pump group (P < .001). Of the total number of 490 anastomoses performed on-pump, 83 (17%) were side-to-side and of 349 anastomoses performed off-pump, 51(15%) were side-to-side, a nonsignificant difference (P = .4). The aorta was used as a site for proximal anastomosis of 1 or more arterial conduits in 105 patients (58%) who underwent on-pump surgery and in 57 patients (40%) who underwent off-pump surgery (P = .002). In the off-pump group, the right internal thoracic artery (RITA) was rarely (12%) routed through the transverse sinus to circumflex branches compared with the on-pump group (34%) (P = .017). RITA in off-pump patients was more often used to revascularize the anterior wall (47% versus 29%; P = .08). We observed no difference in mortality (1.7% versus 0%; P = .3), incidence of perioperative myocardial infarction (8.8% versus 7.7%; P = .8), stroke (1.7% versus 1.4%; P = .8), or atrial fibrillation (24% versus 19%; P = .3). We observed less inotropic support and less blood-product use in off-pump patients. Total arterial revascularization for multiple-vessel coronary artery disease may be safely performed off-pump. We observed tendency to somewhat smoother postoperative course in the off-pump group.

The dilemma of skeletonized internal thoracic artery sequential bypass versus proximal pedicled in situ internal thoracic artery plus coronary-coronary free internal thoracic artery bypass for multiple lesions of the left anterior descending coronary artery

The dilemma of skeletonized internal thoracic artery sequential bypass versus proximal pedicled in situ internal thoracic artery plus coronary-coronary free internal thoracic artery bypass for multiple lesions of the left anterior descending coronary artery