Temporary Shunt Research Articles

Chronic Visceral Artery Obstruction Associated with Hypoplastic Aorta in a Pair of Monozygotic Twins

We report a case of chronic visceral artery obstruction associated with a hypoplastic aorta in a pair of monozygotic twins. They had suffered from abdominal angina and intermittent claudication. The younger twin underwent simultaneous visceral artery reconstruction and right common iliac-femoral artery bypass at age 30. The older twin underwent a visceral artery reconstruction at age 34, 4 years after bilateral common iliac-femoral artery bypass. We used a temporary shunt in order to ensure perfusion for the visceral organs, because there was a rich collateral circulation to visceral organs from the inferior mesenteric artery (IMA) and the internal iliac arteries.

Temporary subcutaneous peritoneal shunts for the treatment of cerebrospinal fluid fistulas following operations on the spine for congenital anomalies

Results The CSF fistulas were resolved in all. Two patients required revisions of the shunt prior to resolving the fistula and subsequent shunt removal. Three patients acquired a lumbar wound/shunt infection, which necessitated shunt removal. Subsequent to removal, the infection resolved and there was no recurrence of the CSF leak. All patients but two had their shunts completely removed within one year of placement (Range: 2–21 months, Mean: 8.7 ± 5.0 months SD). Two patients did not have their shunts removed due to parental decision for no further surgery. Conclusion We conclude that spinal postoperative subcutaneous CSF fistulas may be successfully treated with temporary subcutaneous peritoneal shunts. This reduces hospital stay and more extensive or multiple surgical interventions. from 50th Annual Meeting of the Society for Research into Hydrocephalus and Spina Bifida Cambridge, UK. 30 August – 2 September 2006

Tactical Surgical Intervention With Temporary Shunting of Peripheral Vascular Trauma Sustained During Operation Iraqi Freedom: One Unit??s Experience

Rapidly restoring perfusion to injured extremities is one of the primary missions of forward military surgical teams. The austere setting, limited resources, and grossly contaminated nature of wounds encountered complicates early definitive repair of complex combat vascular injuries. Temporary vascular shunting of these injuries in the forward area facilitates rapid restoration of perfusion while allowing for deferment of definitive repair until after transport to units with greater resources and expertise. Standard Javid or Sundt shunts were placed to temporarily bypass complex peripheral vascular injuries encountered by a forward US Navy surgical unit during a six month interval of Operation Iraqi Freedom. Data from the time of injury through transfer out of Iraq were prospectively recorded. Each patient's subsequent course at Continental US medical centers was retrospectively reviewed once the operating surgeons had returned from deployment. Twenty-seven vascular shunts were used to bypass complex vascular injuries in twenty combat casualties with a mean injury severity score of 18 (range 9-34) and mean mangled extremity severity score of 9 (range 6-11). All patients survived although three (15%) ultimately required amputation for nonvascular complications. Six (22%) shunts clotted during transport but an effective perfusion window was provided even in these cases. Temporary vascular shunting appears to provide simple and effective means of restoring limb perfusion to combat casualties at the forward level.

Abdominal Aortic Aneurysm Repair in Kidney Transplant Recipients

Renal transplant recipients currently survive many years with a consequent increase in the risk of presentation with vascular diseases. So aortic reconstruction in transplant patients has been increasingly reported the most common procedures involving abdominal aorta aneurysms (AAAs). The most important problem during the operation is ischemic injury to the transplanted kidney during aortic clamping. Protection for the grafted kidney from ischemic or reperfusion injury may be achieved by permanent or temporary axillo-femoral, femoro-femoral, aorto-iliac bypass, cold perfusion, local cold preservation, or autotransplantation. Some authors have reported protection of the transplanted kidney function without any other procedures. We had experience with four AAA cases in kidney transplant patients, including two cases of direct reconstruction of the AAA without any other surgical protection, one autotransplantation, and one AAA excision with using temporary aortofemoral bypass with good results. Herein, we report two cases of successful AAA excision without a surgical procedure for graft protection.

Penetrating injuries to the pelvis

As criminality and weapon use increase, general and military surgeons are increasingly confronted with penetrating pelvic injuries both at home and on peacekeeping missions. Penetrating injuries to the iliac vascular axis are associated with considerable mortality, and thus the majority of these emergency patients arrive in a state of deep hypovolemic shock. Concomitant bowel injuries are present in one of five cases, resulting in contamination of the damaged area. Surgical options are simple lateral repair, ligation of the veins, temporary shunt insertion, and prosthetic graft interposition in the injured artery. In extremis ligation of the common or external iliac artery may be the only option to save the patient's life. Surgeons must be aware that damage control surgery and related methods may be needed early on to enable patient survival.

Temporary transjugular intrahepatic portosystemic shunt to overcome small-for-size syndrome after right lobe adult split liver transplantation

Temporary transjugular intrahepatic portosystemic shunt to overcome small-for-size syndrome after right lobe adult split liver transplantation

Robotic Replacement of the Descending Aorta in Human Cadaver

Robot-assisted replacement of the thoracic aorta was performed in a human cadaver. Temporary shunt bypass was established by inserting a left axillary artery catheter and directing it through the aortic arch toward the right femoral artery through the abdominal aorta. The technique utilized the da Vinci surgical system inserted through the 4-cm supramammary working port and two additional thoracoscopic ports. The working port allowed the introduction of an endoscope, endoscopic instruments, and artificial graft and suture materials. The aorta was dissected using the robotic instruments and was clamped with two transthoracic clamps. After transaction of the aorta, a 20-mm polytetrafluoroethylene graft was cut and an end-to-end anastomosis was then performed with running 3-0 Prolene sutures with robotic instruments. The robotic system provides superior optics and allows for enhanced dexterity. Minimally invasive robotic replacement of the descending aorta is an effective procedure and may add benefits for both surgeon and patients.

Graft to Coronary Artery Shunt During Off-Pump Coronary Artery Bypass Grafting

We have developed a simple technique for temporary shunt from the saphenous vein graft to the coronary artery during off-pump coronary anastomosis. The ends of a 2-mm diameter tube were inserted into the distal end of the saphenous vein graft in which proximal anastomosis had been established and into the right coronary artery crux. Blood flow sufficient to maintain adequate hemodynamics was obtained through the shunt tube while suturing around the tube. We successfully employed this technique in 5 patients with acute coronary syndrome. We suggest that this technique may represent an addition to the armamentarium for off-pump anastomosis to the right coronary artery.

The Use of Temporary Vascular Shunts as a Damage Control Adjunct in the Management of Wartime Vascular Injury

While the use of vascular shunts as a damage control adjunct has been described in series from civilian institutions no contemporary military experience has been reported. The objective of this study is to examine patterns of use and effectiveness of temporary vascular shunts in the contemporary management of wartime vascular injury. From September 1, 2004 to August 31, 2005, 2,473 combat injuries were treated at the central echelon III surgical facility in Iraq. Vascular injuries were entered into a registry and reviewed. Location of shunts was divided into proximal and distal, and shunt patency, complications and limb viability were examined. There were 126 extremity vascular injuries treated. Fifty-three (42%) had been operated on at forward locations and 30 of 53 (57%) had temporary shunts in place upon arrival to our facility. The patency for shunts in proximal vascular injuries was 86% (n = 22) compared with 12% (n = 8) for distal shunts (p < 0.05). All shunts placed in proximal venous injuries were patent (n = 4). Systemic heparin was not used and there were no shunt complications. All shunted injuries were reconstructed with vein in theater and early viability for extremities in which shunts were used was 92%. Temporary vascular shunts are common in the management of wartime vascular injury. Shunts in proximal injuries including veins have high patency rates compared with those placed in distal injuries. This vascular adjunct represents a safe and effective damage control technique and is preferable to attempted reconstruction in austere conditions.

Upper Extremity Vascular Injury: A Current In-Theater Wartime Report from Operation Iraqi Freedom

Past wartime experience and recent civilian reports indicate upper extremity (UE) vascular injury occurs less often and with less limb loss than lower extremity (LE) injury. Given advances in critical care, damage control techniques, and military armor technology, the objective of this evaluation was to define contemporary patterns of UE injury and effectiveness of vascular surgical management in UE vascular injury during Operation Iraqi Freedom (OIF). From 1 September 2004 through 31 August 2005, 2,473 combat-related injuries were treated at the central echelon III surgical facility in Iraq. Patients with UE vascular injuries upon arrival were reviewed. Vessels injured were delineated. Therapeutic interventions, early limb viability, and complication rates following vascular repair were recorded. Of casualties treated during the study period, 43 (1.7%) UE and 83 (3.3%) LE vascular injuries were identified. Of the UE injuries, 11 (26%) had been operated on at forward locations and six (14%) had temporary shunts in place upon arrival at our facility. Injury levels included 10 (23%) subclavian-axillary, 25 (58%) brachial, and 10 (23%) distal to the brachial bifurcation. Two patients had multilevel injury. Twenty-eight grafts were placed, and 10 vessel repairs and eight ligations were performed. Two (4.7%) brachial interposition grafts required removal due to infection. Four (9.3%) subacute brachial graft thromboses occurred. Four (9.3%) patients underwent early UE amputation. In this most recent U.S. military evaluation of wartime UE vascular injury, UE injury appears rare, with LE injury twice as frequent. Yet, UE limb loss appears more substantial than noted previously. These findings are likely related to significant tissue destruction occurring with the combined mechanisms of injury sustained in OIF.

Inflow Stenoses in Dysfunctional Hemodialysis Access Fistulae and Grafts

The aim of the study is to prospectively determine the incidence of inflow stenoses in dysfunctional hemodialysis access arteriovenous fistulae (AVFs) and grafts (AVGs). Contrast-enhanced magnetic resonance angiography (CE-MRA) was performed of 66 dysfunctional AVFs and 35 AVGs in 56 men and 45 women (mean age, 62 years; age range, 31 to 86 years). Complete inflow (from the subclavian artery), shunt region, and complete outflow (including subclavian vein) were shown at CE-MRA. In addition to standard digital subtraction angiography (DSA) of the shunt region and outflow, DSA of the complete inflow was obtained through access catheterization of all cases in which CE-MRA showed an inflow stenosis. Vascular stenosis is defined as greater than 50% decrease in luminal diameter compared with an uninvolved vascular segment located adjacent to the stenosis. Endovascular intervention of stenoses was performed in connection with DSA. CE-MRA showed 19 arterial stenoses in 14 patients (14%). DSA confirmed 18 of these lesions in 13 patients and showed no additional inflow lesions. Of the 13 patients, 7 patients had arterial stenoses only and 6 patients had accompanying stenoses in the shunt region and/or outflow. Referral criteria for the 13 patients to undergo access evaluation had been decreased flow rates (9 patients), steal symptoms (2 patients), and insufficient access maturation (2 patients). Access flow of the 9 patients with a low-flow access improved from 477 +/- 74 mL/min to 825 +/- 199 mL/min after angioplasty. One patient with steal symptoms became symptom free after angioplasty. Endovascular intervention in 3 patients proved to be unsuccessful. Inflow stenoses are not uncommon in dysfunctional hemodialysis access shunts. We suggest that radiological evaluation comprise assessment of the complete arterial inflow.

Commentary on "The Use of Temporary Vascular Shunts as a Damage Control Adjunct in the Management of Wartime Vascular Injury"

Commentary on "The Use of Temporary Vascular Shunts as a Damage Control Adjunct in the Management of Wartime Vascular Injury"

Staged Anesthesia for Combined Carotid and Coronary Artery Revascularization: A Different Approach

Combined coronary artery bypass graft (CABG) surgery and carotid endarterectomy (CEA) are performed in an attempt to reduce the risk of postoperative stroke after CABG surgery in patients with significant or symptomatic carotid artery stenosis. The choice between regional and general anesthesia for CEA is still under debate. Regional anesthesia offers an excellent monitoring technique of the neurologic status of the awake patient during carotid clamping. In an attempt to improve monitoring of the neurologic status and avoid the use of temporary shunting in patients undergoing the combined procedure, a different approach is described combining regional anesthesia for CEA followed immediately by general anesthesia for CABG surgery. Prospective nonrandomized case series. University hospital. Twenty patients scheduled for combined CEA and CABG surgery underwent a "staged" anesthetic approach from January to December 2004. Pulmonary, femoral artery, and urinary catheters were inserted under local anesthesia. A deep cervical plexus block was then performed and supplemented by a superficial cervical plexus block. The patient was draped for standard combined CEA and CABG surgery. CEA was then performed using standard techniques. Without altering the surgical field, general anesthesia was given and endotracheal intubation performed following the successful CEA. Coronary revascularization was then completed. CEA and CABG surgery were completed successfully in all patients. There was no need for conversion from local to general anesthesia. Endotracheal intubation was easily performed in all patients. There was no hospital mortality in this series. No neurologic events were observed during the CEA. A reversible ischemic stroke, ipsilateral to the CEA, occurred postoperatively on awakening from CABG surgery in 1 patient. This staged anesthetic approach for combined CABG and CEA surgery is an alternative in this complex subset of patients.

Bidirectional glenn shunt without cardiopulmonary bypsss

Objective: The aim of this study is to review the experience of using bidirectional Glenn shunt without cardiopulmonary bypass(CPB). Methods: Fifty-eight patients underwent bidirectional Glenn shunt without CPB between May, 2000 and September, 2001. The age was (3.65±1.59) years and the weight was (13.6±4.0) kg. The procedure consists of establishing temporary bypass with cannulae placed in the SVC and right auricular appendage for venous drainage and transection of right SVC. The cardiac end of the SVC is overseen. The cranial end is anastomosed to a longitudinal incision in the superior margin of the right pulmonary artery with absorbable running suture. The anterior wall of the anastomosis is widened with pericardium patch. Results: There was no operative mortality. Five cases had postoperative complications including coma in 1 and chylothorax in 4. The mean SVC crossclamp time was (48±15) mins. The preoperative oxygen saturation and CVP were 0.75±0.09 and (12.8±2.3) mmHg, respectively. While the postoperative oxygen saturation and CVP were 0.93±0.05 and (16.5±2.9) mmHg, respectively. The drainage was (145±103)ml. The average mechanical ventilation time was (13±7) hrs. The mean postoperative hospital stay was (10±5) days. Conclusion: Bidirectional Glenn shunt without CPB is a safe and reliable method, for complicated congenital heart diseases children with inadequate pulmonary blood flow when anatomic and primary physiological correction are not suitable.

Temporary Right Heart Support With Percutaneous Jugular Access

Temporary right heart bypass has shown to improve hemodynamic stability and safety in beating heart revascularization. We sought to evaluate feasibility and safety of a right ventricular assist device percutaneously implanted in the right jugular vein. The A-Med jugular coaxial cannula (A-Med Systems Inc, West Sacramento, CA) is designed for percutaneous implantation. Blood from the right heart is drained through the outer tube of this two-cannula device to a microcentrifugal pump and returned into the pulmonary artery through the inner tube. In 10 patients scheduled for elective coronary bypass grafting without cardiopulmonary bypass, a total of 27 coronary anastomoses were performed with right heart support. Arterial pressure was significantly higher with right heart support when the heart was dislocated to access posterior and posterolateral anastomosis sites. Implantation through the right internal jugular vein was feasible without complications in all patients and facilitated the procedure. This initial study suggests safety and feasibility of temporary right heart support using percutaneous jugular access for posterior and posterolateral coronary bypass grafting.

Liver Transplantation for Fulminant Hepatic Failure Without Venovenous Bypass and Without Portacaval Shunting

Preservation of the caval vein during liver transplantation (OLT) has gained wide acceptance but portosystemic bypass or temporary portocaval shunt is still believed to be indicated in patients with fulminant hepatic failure. Herein we have described our initial experience with piggyback OLT without venovenous bypass and without portocaval shunting in five such patients. Division of the portal vein was always delayed until the native liver was completely dissected off the caval vein. The donor hepatic artery was anastomosed to the recipient aorta via an iliac interposition graft placed in the supraceliac position in two and at an infrarenal site in three patients. The ahepatic phase urinary output was low in the two patients in whom we applied supraceliac cross-clamping of the aorta. The mean ahepatic phase was 53 (45 to 67) minutes in four recipients who remained hemodynamically stable throughout surgery and prolonged to 5 hours in one patient due to a complicated supraceliac aortic anastomosis. Its repair resulted in hemodynamic instability, multiorgan failure, and death at 4 days following OLT. Four (80%) patients are alive in good condition with normal liver function after a mean of 12 (5 to 25) months of follow-up. In summary, liver transplantation for fulminant hepatic failure may be safely performed without venovenous bypass and without temporary portocaval shunting if the ahepatic phase is minimized and portal flow to the liver maintained up to the moment of hepatic excision. Arterial anastomosis with the supraceliac aorta prolongs the ahepatic phase and may impair kidney function: therefore, it should be avoided in these patients.

Extensive surgical management for renal tumors with inferior vena cava thrombus.

The aim of this study was to evaluate the outcome in patients with renal cell carcinoma (RCC) and the inferior vena cava (IVC) or the right atrium tumor thrombus that were treated with radical nephrectomy and thrombectomy. Eleven of a total of 105 patients who underwent radical nephrectomy due to RCC had tumor thrombus extended to the IVC and/or the right atrium. We evaluated the surgical techniques used and the perioperative mortality and morbidity in these patients. The median age of the patients was 47 years (range, 16 to 59 years). They all underwent radical nephrectomy with cavotomy, tumor thrombus removal, and lymphadenectomy. Eight patients underwent extracorporeal circulation and hypothermic circulatory arrest; 2, temporary venovenous bypass by chevron incision and median sternotomy; and 1, only chevron incision with mobilization of the right lobe of the liver and cross-clamping proximal to the tumor thrombus and cavotomy. In 1 case, a solitary liver metastasis was excised and the patient died within 30 days postoperatively because of massive hemorrhage due to liver metastatectomy. Two patients had invasion to the IVC wall and 7 had pathological lymph node involvement. Four patients were tumor free (follow-up range, 9 to 18 months) and 7 died due to multiple metastases during the follow-up. This study supports the role of extensive surgical treatment as the best initial management of patients with renal cancer extended to the IVC only in highly selected cases.

Surgical treatment of aneurysm of the thoracic aorta under a temporary external by-pass shunt.

Abstract Twenty-eight patients were operated upon for aneurysm of the thoracic aorta using a temporary external by-pass shunt. Four early deaths occurred, the cause of which could not be related to the by-pass procedure itself. The temporary long external by-pass from the left subclavian artery or from the ascending aorta to the femoral artery was preferable for resection of an aneurysm of the descending aorta or the distal aortic arch which required cross-clamping of the aorta.

Experimental experience with a temporary intraluminal heparin-bonded polyurethane arterial shunt.

After vascular injury, intraluminal arterial shunting may be employed if definitive surgery must be delayed. This paper describes use of a heparin-bonded polyurethane shunt to restore distal circulation after ligation of the femoral artery in sheep. In studies to determine tissue viability for 12 h after insertion into the femoral artery, five of seven shunts remained patent. In another series of experiments to study tissue viability after limb ischaemia, the femoral artery was ligated and a tight Esmarch bandage applied to the limb for 6 h before shunt insertion. The shunt remained patent for 12 h in five of six cases. Nearly all shunt failures occurred shortly after placement and were attributable to intimal damage arising from difficulties during insertion.

Use of a percutaneous atrial septal occluder device for complete acute occlusion of an intrahepatic portosystemic shunt in a dog

A 3-month-old sexually intact male German Shepherd Dog was evaluated because of signs of depression, ataxia, and collapse. Clinicopathologic abnormalities included low serum BUN and albumin concentrations and high serum liver enzyme activities and plasma ammonia and serum bile acids concentrations. Abdominal ultrasonography revealed an intrahepatic portosystemic shunt (PSS). The dog was anesthetized; via a transjugular approach, guidewires and catheters were directed with fluoroscopic guidance to locate the shunt and determine its anatomic features. Minimal changes in portal vein pressure during temporary shunt balloon occlusion enabled complete shunt attenuation, which was performed by use of a self-expanding septal occlusion device that is typically used for treatment of atrial septal defects in humans. Following initial misplacement of the device, the procedure was repeated successfully 2 months later and resulted in complete shunt occlusion. One year after this second procedure, the dog was clinically normal and serum bile acids concentration was within reference limits. In certain dogs with intrahepatic PSSs, treatment with minimally invasive interventional techniques involving fluoroscopy may reduce the morbidity and mortality rates associated with more invasive surgical procedures.