Temporary Shunt Research Articles

Temporary Cerebral Revascularization Using a Radial Artery in the Hand-Eyeshade Posture: Technical Note

Kamiyama introduced a unique method of temporary cerebral revascularization using a radial artery graft (RAG) in his technical review. We tried original method with Sugita frame, and pointed out some disadvantages that include to avoid taking instruments or hands in and out, stability of hands, and unrestricted usage of brain retractors during temporary bypass between radial artery and M2 potion of middle cerebral artery (RA-M2 bypass). To solve those disadvantages, especially for Sugita head frame users, we here present a modified Kamiyama's method of temporary cerebral revascularization with the forearm elevated over the face like as hand-eyeshade posture.

Overview of the 2012 Food and Drug Administration circulatory system devices panel meeting on the reclassification of external counterpulsation, intra-aortic balloon pump, and non–roller-type cardiopulmonary bypass blood pump devices

The Food and Drug Administration held a Circulatory System Devices Advisory Panel meeting, December 5 and 6, 2012, to review the classification or potential reclassification of the following device types: external counterpulsation, intra-aortic balloon pump (IABP), and non-roller-type cardiopulmonary bypass blood pumps. These 3 devices are preamendment (Medical Device Amendments of 1976) class III devices. The advisory panel discussed the data and provided recommendations for reclassification of these devices. The panel recommended reclassification of ECP to class II for stable angina pectoris and to retain a class III for all other indications. For IABP, the recommendation was to reclassify IABP to class II for several indications (acute coronary syndrome, cardiac and noncardiac surgery, and heart failure complications) and remain class III for all other indications. As for non-roller type, the panel recommended that for cardiopulmonary bypass and temporary circulatory bypass, these devices should be reclassified to class II while retaining a class III device status for all other indications, including ventricular support both for hemodynamically unstable patients and for prophylactic support in high-risk percutaneous interventions.

Clinical outcomes of temporary shunting for infants with cerebral pseudomeningocele

Although in the case of subdural collections temporary shunting has been suggested as a viable alternative for definitive drainage of the accumulated fluid until restoration of the normal CSF dynamics, there is no agreement on the best management strategy for pseudomeningocele. The authors performed a retrospective chart review in order to evaluate the clinical outcomes of infants temporarily shunted for pseudomeningocele without encephalocele at our institution (The University of Illinois at Peoria/Illinois Neurological Institute) in the period from 2004 to 2012. The epidemiological characteristics, clinical management, and final outcomes of such subpopulation were compared with a control group which received temporary shunting for subdural hematomas (SDH) during the same period. Four patients (100% male) ranging in age from 8.9 to 27.1 months (mean = 13.88) with pseudomeningocele and 17 patients (64.7% male) ranging in age from 1.9 to 11.8 months (mean = 4.15) with SDH were identified. Although the initial management included sequential percutaneous subdural tapping in 82% of the patients, all children ultimately failed such strategy, requiring either subdural-peritoneal (81% of the cases) or subgaleal-peritoneal (19% of the cases) shunting. The mean implant duration was 201 days for the pseudomeningocele group and 384 days for the SDH one. Mean post-shunt hospitalization was 2 days for patients with pseudomeningocele and 4 days for patients with SDH. There was no statistical difference in terms of complications, length of hospitalization post-shunting, or clinical outcomes between the patients with pseudomeningocele and those with SDH. Temporary shunting of infants with pseudo-meningocele constitutes a viable therapeutic alternative with favorable clinical outcomes and a low risk of shunt dependency similar to those of children with SDH.

Changing Treatment Strategy From Clipping to Radial Artery Graft Bypass and Parent Artery Sacrifice in Patients With Ruptured Blister-Like Internal Carotid Artery Aneurysms

Blood blister-like aneurysms (BBAs) are aneurysms with ill-defined fragile necks arising from an internal carotid artery (ICA) and associated with high mortality. To describe strategies and outcomes in patients in whom radial artery (RA) graft bypass with ICA sacrifice was considered as the primary treatment during the acute phase of subarachnoid hemorrhage. The authors analyzed the clinical records of 20 patients who were treated between 2004 and 2011 at their hospital and affiliate institutions. A majority of the patients were treated during the acute phase (<24 hours, n = 15). A favorable outcome was achieved in 18 (90%) patients. The treatment strategies used were as follows: (1) ICA trapping/external carotid artery (ECA)-RA-middle cerebral artery (MCA) bypass (n = 13), (2) ICA trapping/superficial temporal artery-MCA bypass (n = 2), (3) aneurysm clipping with RA-MCA temporary bypass (n = 3), (3) aneurysm clipping with proximal ICA ligation and ECA-RA-MCA bypass (n = 1), and (4) direct clipping (n = 1). Postoperative infarction was observed in 6 patients and was ascribed to vasospasm (n = 1), retrograde thrombosis associated with trapping (n = 2), and reasons unrelated to the surgical procedures (n = 3). Trapping with RA graft bypass demonstrated favorable results in patients with internal carotid BBAs. Although trapping/RA graft bypass is a definitive treatment for BBAs located proximal to the origin of the posterior communicating artery, some distal BBAs preclude ICA trapping to spare the perforating arteries.

A new method for protection from shower embolism during TEVAR on a shaggy aorta

The case of a patient with a thoracoabdominal aortic aneurysm accompanied by a shaggy aorta, in whom embolism was prevented by a graft used in debranching and placement of an extracorporeal shunt during thoracic endovascular aortic repair, called the "block and trap method", is presented. Two-staged operations were performed using Y graft replacement, debranching bypass, and thoracic endovascular aortic repair during which a temporary shunt line with a blood filter was made involving the femoral artery and vein. The method of trapping emboli in a filter in an external shunt appears effective.

Primary synovial sarcoma of the lung successfully resected under temporary bypass

A 48-year old man presented with chest pain and haemoptysis. Chest computed tomography showed a 60-mm mass in the left upper lobe of the lung, adjacent to the distal aortic arch. Bronchoscopic cytology revealed the presence of malignant cells and, in the absence of evidence of distant metastasis, a thoracotomy was performed. Although the tumour was firmly adherent to the distal aortic arch, under temporary bypass from the left subclavian artery to the descending aorta, it was successfully resected en bloc with the section of the aorta attached to it. The tumour was diagnosed as a primary synovial sarcoma of the lung on the basis of histopathological findings and fluorescent chromogenic in situ hybridization, showing SS18 gene rearrangement.

Temporary intraoperative porto-caval shunt: useless or beneficial in piggy-back liver transplantation?

Temporary intraoperative porto-caval shunt: useless or beneficial in piggy-back liver transplantation?

Aberrant Right Subclavian Artery and Kommerell's Diverticulum: An Original Surgical Treatment with Dual-purpose Shunt

Introduction We report a case of Kommerell's diverticulum of an aberrant right subclavian artery in a patient with a left-sided aortic arch. Report The 80-year-old patient presented with dysphagia and dyspnea. The computed tomography scan showed that the trachea and the esophagus were compressed by the aberrant artery. This situation was corrected by surgical treatment without cardiopulmonary bypass or hypothermic circulatory arrest. The aneurysm was excluded by means of a temporary shunt between the ascending aorta and the descending aorta. Discussion An endovascular procedure was not considered to be appropriate to release the esophagus and trachea from arterial compression.

Aberrant Right Subclavian Artery and Kommerell's Diverticulum: An Original Surgical Treatment with Dual-purpose Shunt

Introduction: We report a case of Kommerell's diverticulum of an aberrant right subclavian artery in a patient with a left-sided aortic arch. Report: The 80-year-old patient presented with dysphagia and dyspnea. The computed tomography scan showed that the trachea and the esophagus were compressed by the aberrant artery. This situation was corrected by surgical treatment without cardiopulmonary bypass or hypothermic circulatory arrest. The aneurysm was excluded by means of a temporary shunt between the ascending aorta and the descending aorta. Discussion: An endovascular procedure was not considered to be appropriate to release the esophagus and trachea from arterial compression. Aberrant Right Subclavian Artery and Kommerell's Diverticulum: An Original Surgical Treatment with Dual-purpose ShuntEJVES ExtraVol. 26Issue 1PreviewWe report a case of Kommerell's diverticulum of an aberrant right subclavian artery in a patient with a left-sided aortic arch. Full-Text PDF Open Access

Temporary Extracorporeal Brachio-Femoral Vascular Prosthesis Shunt for Ischemia Prevention in an Operation for Abdominal Aortic and Iliac Aneurysms in a Patient with Marfan^|^apos;s Syndrome

In open vascular repair, when prolonged infrarenal aortic clamping can be expected, and collateral perfusion is reduced, the use of a temporary shunt may reduce the risk of ischemic complications. In a patient with Marfan's syndrome and aortic dissection who had developed infrarenal aneurysms, segmental arteries had been occluded by prior aortic surgery and collateral arteries in the anterior torso could have been damaged by previous pectus excavatum, muscle flap, sternotomy, and ventral hernia operations. The axillary artery was dilated. For the prevention of ischemia during open repair with a bifurcated graft, a temporary extracorporeal brachio-femoral vascular prosthesis shunt was constructed. Ischemia was not observed. The use of a temporary extracorporeal brachio-femoral shunt with a vascular prosthesis is a feasible method for ischemia prevention.

Recanalization of Acute Intracranial Artery Occlusion Using Temporary Endovascular Bypass Technique

PurposeThe purpose of this study is to present our preliminary experience of the temporary endovascular bypass (TEB) technique using an Enterprise stent for recanalization of acute intracranial artery (IA) occlusion.Materials and MethodsPatients treated by TEB were enrolled in this retrospective study from January 2009 to May 2010. All the procedures consist of temporary partial deployment and subsequent retrieval of Enterprise stent, supplemented by intra-arterial infusion of urokinase (UK) and/or tirofiban. According to the thrombolysis in cerebral infarction (TICI) classification, recanalization was evaluated with initial and postprocedural angiography. Safety was evaluated related to the procedure and clinical outcomes were assessed by National Institute of Health Stroke Scale (NIHSS) score at discharge and modified Rankin scale (mRS) score at 3 months.ResultsEleven patients (median NIHSS 12.8, mean age 61.6 years, male: female = 8:3) with acute IA occlusion were treated with TEB. All the patients presented with TICI 0, and the occluded vessel was the middle cerebral artery (n=7), the basilar artery (n=1), and the distal ICA occlusion (n = 3). IV infusion of tissue plasminogen activator (tPA) was done in 4 patients and mechanical thrombolysis with intra-arterial UK was performed in 9. Recanalization was achieved in 73% (8 patients; TICI ≥ 2). There were no procedure-related complications except for two asymptomatic intracranial hemorrhages. Improvement (≥ 4 points on the NIHSS) and good outcome (mRS ≤2) after 90 days was shown in six patients (55%). One patient died 6 days after procedure.ConclusionTEB may be a valuable treatment option in acute thromboembolic IA occlusion without stent implantation.

Role of Endovascular Grafts in Combined Vascular and Skeletal Injuries of the Lower Extremity: a Preliminary Report

BackgroundA gunshot wound to the lower extremity with combined skeletal and vascular injuries can be difficult to manage. In clinical practice, it is not always possible to assemble a multispecialty team to work seamlessly to attain this goal, and the end result may be unnecessary prolonged ischemic time. A covered endovascular stent (EVS) can be used initially to restore perfusion without need of a time-consuming temporary shunt in select cases.ObjectivesThe objective of this study is to compare novel methods of repairing the superficial femoral artery to the traditional three-step operative approach in patients that have a concomitant femur fracture.Patients and MethodsAll patients with combined vascular and skeletal injuries to the lower extremity were reviewed retrospectively. Patients were divided into three groups: Group 1: EVS placed percutaneously. Group 2: EVS placed with a hybrid combination of open and endovascular technique. Group 3: Placement of temporary shunt followed by skeletal stabilization and definitive vascular repair.ResultsThere were 16 patients identified. Group 1 = three, Group 2 = six, Group 3 = seven. EVS can shorten time to revascularization and prevents a second episode of vascular interruption at the time of the final vascular repair. The structural stability of the EVS was strong enough to withstand the skeletal manipulation without deformation of the stent.ConclusionsEVS is comparable to open repair and has the strength to withstand orthopedic manipulation in the short term when used in combined vascular and skeletal injuries to the lower extremity. Ischemic time is reduced significantly if final revascularization is accomplished at the onset with an EVS and the process is more efficient if the trauma surgeon is able to repair the vascular injury. With increasing sophistication of endovascular devices, this offers an appealing approach to vascular injuries that will decrease ischemic and total operative times when compared to the more traditional three-stage repair.

Temporary extracorporeal axillo-iliac vascular prosthesis shunt in open repair of a pararenal aortic aneurysm

When a long aortic clamp time is expected or when upper body to lower body collateral arteries are sparse, temporary lower body perfusion may be needed to reduce ischemic injury during supraceliac clamping in open repair of pararenal aortic aneurysms. The use of conventional extracorporeal perfusion techniques carry extra risks and is not in the armamentarium of most vascular surgeons. An axillo-femoral or -iliac shunt using a vascular prosthesis does not require the same degree of anticoagulation and causes less activation of blood components. A patient, who had extensive vascular stenotic disease and large bowel ischemia, was operated on for a pararenal aortic aneurysm while the lower body was perfused via a temporary extracorporeal vascular prosthesis axillo-iliac shunt. Copious backbleeding encountered while suturing the proximal anastomosis testified to the efficacy of the temporary shunt. A left hemicolectomy had to be performed for gangrene of the sigmoid colon and he needed 2 days of respiratory support; otherwise the postoperative course was uneventful. In our case more ischemic injury than that observed might have been expected without the temporary bypass but significant backbleeding may have negated some of the beneficial effect of the shunt. A temporary axillo-femoral or -iliac shunt prevents lower limb ischemia and provides an ample amount of collateral blood flow to the torso. It does not need to be buried subcutaneously as previously described. Occlusive balloons should be used where possible to prevent backbleeding and to further increase available collateral blood supply.

Novel Visceral-Anastomosis-First Approach in Open Repair of a Ruptured Type 2 Thoracoabdominal Aortic Aneurysm: Causes behind a Mortal Outcome

Case reports to analyze causes and possible prevention of complications in a new setting are important. We present an open repair of a ruptured type 2 thoracoabdominal aortic aneurysm in a 78-year-old man. Lower-body perfusion through a temporary extracorporeal axillobifemoral arterial prosthesis shunt was combined with the use of a branch to the permanent aortic prosthesis to enable rapid visceral revascularization using a visceral-anastomosis-first approach. The patient died due to transfusion-induced capillary leak syndrome and left colon necrosis; the latter was probably caused by a combination of back-bleeding from lumbar arteries causing a steal effect, an accidental shunt obstruction, and hemodynamic instability towards the end of the operation. The visceral-anastomosis-first approach did not contribute to the complications. This approach reduces the time when visceral organs are perfused only via collateral arteries to the time needed for suturing the visceral anastomoses. This may be important when collateral perfusion is marginal.

A Modified Technique of Direct Aortic Arch Debranching Using a Shunt for Cerebral Perfusion Protection During Hybrid Repair of an Aortic Arch Aneurysm

Abstract Introduction We report a 74-year-old man with highly advanced arteriosclerosis and aortic arch aneurysm and who had a past medical history of cerebral infarction. Case report Recurrence of cerebral infarction during operation if cerebral blood flow decreased during debranching of the cerebral arteries was a concern. A direct reconstruction to the arch vessels was carried out with a temporary shunt blood circuit using a 12-Fr balloon perfusion catheter to prevent cerebral ischaemia, and thoracic endovascular aneurysm repair was performed. Discussion This method is safe and useful for elderly persons with advanced arteriosclerosis.

A Modified Technique of Direct Aortic Arch Debranching Using a Shunt for Cerebral Perfusion Protection During Hybrid Repair of an Aortic Arch Aneurysm

Introduction: We report a 74-year-old man with highly advanced arteriosclerosis and aortic arch aneurysm and who had a past medical history of cerebral infarction. Case report: Recurrence of cerebral infarction during operation if cerebral blood flow decreased during debranching of the cerebral arteries was a concern. A direct reconstruction to the arch vessels was carried out with a temporary shunt blood circuit using a 12-Fr balloon perfusion catheter to prevent cerebral ischaemia, and thoracic endovascular aneurysm repair was performed. Discussion: This method is safe and useful for elderly persons with advanced arteriosclerosis. A Modified Technique of Direct Aortic Arch Debranching Using a Shunt for Cerebral Perfusion Protection During Hybrid Repair of an Aortic Arch AneurysmEJVES ExtraVol. 25Issue 1PreviewWe report a 74-year-old man with highly advanced arteriosclerosis and aortic arch aneurysm and who had a past medical history of cerebral infarction. Full-Text PDF Open Access

Hybridoperation eines thorakoabdominellen Aortenaneurysmas

The treatment of thoracoabdominal aortic aneurysms remains an ongoing challenge in vascular surgery and has been associated with high periprocedural mortality. Since the introduction of endovascular procedures in the treatment of aortic pathologies during the last decade, new therapeutic options have arisen. We report here some technical aspects of a 2-step hybrid-procedure that consists of an initial debranching of all visceral arteries by perfusing them through a special vascular prosthesis, which is anastomosed to the healthy common iliac artery. The second step is performed after recovery of the patient from the debranching procedure and stentgraft prostheses are implanted to fully exclude the aneurysm. Thoracoabdominal aortic aneurysm. Two-step hybrid-procedure for treatment of thoracoabdominal aneurysms. In our opinion, this procedure is, although technically demanding, safely performable with a tolerable periprocedural morbidity and mortality. Major advantages are the restriction to one visceral cavity and a sequential debranching that allows us to avoid use of a temporary bypass. This procedure appears to be a promising alternative to conventional thoracoabdominal aortic repair in centres with expertise in visceral artery revascularisation.

Penetrating peripheral vascular injury management in a Sri Lankan military hospital.

Vascular injuries in austere military conflict settings are a challenging problem. The goal of the current study was to analyze the unique features associated with the management and early outcome of penetrating vascular injuries resulting from the conflict in Sri Lanka. All adults with extremity vascular injuries admitted to the Military Base Hospital Anuradhapura in an eight-month period were prospectively recorded in a data sheet and retrospectively analyzed. Mechanism, location, method of repair, and outcomes were analyzed. Out of a total of 5,821 combat-related casualties, there were 128 victims with vascular injuries (2.2%). The overall limb salvage rate was 83% with an all-cause mortality of 3.1%. Combined arterial and venous injuries were most common (44%), predominantly in the popliteal zone. Among the arterial injuries, 70% were repaired with a vein interposition graft and 7% were primarily repaired. The majority of the venous injuries (54%) were ligated. Twenty early major complications were recorded. A temporary intraluminal shunting technique was applied in the 14 most severely injured patients. This patient population was followed up for an average of 35days institutionally before they were referred to rehabilitation (60%) or transferred to other institutions (26%). Vascular reconstruction using vein, combined with a wound management strategy and early fasciotomy, resulted in a high limb salvage rate and remarkably low infection, delayed amputation, and mortality rates. Management of combat vascular injuries based on clinical guidance is feasible and leads to good outcome in a minimally equipped setting during local military conflicts. Surgeons in military hospitals should be trained in vascular injury repair to save the lives and functional limbs of patients.

Ingluviotomy Tube Placement for Lead-induced Crop Stasis in the California Condor (Gymnogyps californianus)

Six free-flying California condors (Gymnogyps californianus) were diagnosed with acute lead toxicosis that caused crop distension and stasis. Between January 2006 and January 2007, the birds were referred to the Phoenix Zoo in Arizona for emergency treatment. In 5 birds, an ingluviotomy was performed to place a feeding tube from the crop to the proventriculus, which allowed a temporary bypass of the dysfunctional esophagus until normal function and motility were regained. A crop-support pressure bandage was placed in 4 birds to improve crop emptying into the proventriculus and to prevent crop distension. Although chelation therapy is the gold standard treatment for lead toxicosis, severe cases of lead-induced crop stasis are not acutely reversible with pharmaceuticals. In these condors, placement of a feeding tube was deemed prudent to ensure a viable enteric route of nutritional support during the standard treatment and recovery period in acute lead toxicosis with crop stasis.

Temporary axillobifemoral bypass during fenestrated aortic aneurysm repair

Fenestrated endovascular aortic aneurysm repair (f-EVAR) of juxtarenal aneurysms requiring cannulation of the superior mesenteric artery and renal arteries is technically challenging, has a long operating time, and requires bilateral large-caliber sheath insertion into the femoral arteries. Consequently, the risk of lower limb ischemia and subsequent reperfusion injury is increased. We describe the use of an adjunct temporary axillobifemoral bypass graft (TABFBG) for f-EVAR and propose that it be used as a strategy to avoid ischemia-reperfusion injury in patients anticipated as being at increased risk. Consecutive patients from a tertiary referral center undergoing f-EVAR, between October 2008 and August 2011, were retrospectively analyzed. Patients with lower limb arterial occlusive disease and those with difficult anatomy had an adjunct TABFBG. All patients presenting with a juxtarenal aortic aneurysm were treated endovascularly, regardless of aneurysm anatomy and technical difficulties. There were 37 patients without TABFBG (group 1) and 27 with TABFBG (group 2). No patients required open conversion. Sex and age were not significantly different between the groups. The median ankle-brachial pressure index was significantly higher in group 1 (P=.0001). The groups had similar median blood loss, percentage of target vessel cannulation, and median stay in the intensive therapy unit. Morbidities were similar in both groups. There were no significant differences in cardiac, renal, or respiratory complications between the groups. The 30-day mortality was 10.8% (n=4) in group 1 and 0% in group 2 (P=.046). Our series has demonstrated a significant reduction in mortality (10.8% absolute risk reduction) and no increase in morbidity with the use of a TABFBG for fenestrated grafts. This is likely a result of the reduction in ischemia and ischemia-reperfusion injury in these patients. We therefore recommend the use of TABFBG in patients with proximal severe stenotic or occlusive disease and those in whom an operative time of >4 hours is predicted (typically those for whom three or more target fenestrations is planned).