Type Of Arterial Reconstruction Research Articles

Early Hepatic Artery Thrombosis After Liver Transplantation: What is the Impact of the Arterial Reconstruction Type?

Hepatic artery thrombosis (HAT) is the most severe vascular complication occurring after liver transplantation, with an incidence ranging from 2 to 9% in adults. Although the ideal arterial reconstruction is often described as a short and non-redundant anastomosis fashioned between the recipient and donor hepatic arteries, there is no strong evidence about this ideal reconstruction in the literature. The aim of this study was to assess the impact of the type of arterial reconstruction on early HAT after primary liver transplantation. We retrospectively reviewed a contemporary MELD era cohort of 282 patients who underwent deceased donor primary liver transplantation from 2007 to 2012. Graft artery was classified as "short" when the section was located at the proper/common hepatic artery or "long" when the celiac trunk was used for anastomosis. Recipient arterial sites for arterial anastomosis were classified in three sites: (1) "distal" (proper hepatic artery or common hepatic artery/gastro-duodenal bifurcation), (2) "intermediate" (common hepatic artery) and (3) "proximal" (celiac trunk-splenic artery-aorta). We used univariate and multivariate analyses to assess the impact of different types of arterial reconstruction on early HAT. Of 282 primary liver transplantations, 17 patients (6%) developed early HAT. Patients with and without early HAT had comparable demographic and operative data. The main anastomotic combination was short graft artery on the recipient-common hepatic artery (n=111, 39%). A long graft artery was used in 91 patients (32%) and was associated with hepatic artery variations (56%; n=51; p=0.001). Arterial reconstructions using a long graft artery (p=0.003), a recipient proximal site as celiac trunk-splenic artery-aorta (p=0.02) and the combination of a long graft artery on the recipient distal hepatic artery (p=0.02) were significantly associated with early HAT. The early HAT rate in patients with a long graft artery was not significantly different between patients with or without donor arterial variation (respectively, 12% (n=6/51) vs. 12% (n=5/40); p=1). In multivariate analysis, the use of a long graft artery, whatever the recipient anastomosis site, was an independent risk factor of early HAT (OR 3.2; 95% CI 1.2-9; p=0.02). The type of arterial reconstruction used for arterial anastomosis during primary liver transplantation has an impact on the occurrence of early HAT. The use of a long graft artery is an independent risk factor of early HAT. Thereby, we recommend the use of a short graft artery with a direct path when feasible to reduce the occurrence of early HAT after primary liver transplantation.

Patient survival after open and endovascular mesenteric revascularization for chronic mesenteric ischemia

To evaluate long-term patient survival and causes of death after open (OR) or endovascular (ER) mesenteric revascularization for atherosclerotic chronic mesenteric ischemia using propensity score-matched comparison and clinical risk stratification. The clinical data of 343 patients treated with mesenteric revascularization for chronic mesenteric ischemia between 1991 and 2010 were retrospectively reviewed. Clinical, anatomical, and procedure-related variables were analyzed using a multivariate model to identify independent predictors of any-cause early and late (>30 days) mortality. Cause of death was retrieved from review of the National Death Index. Patient survival was analyzed using Society for Vascular Surgery (SVS) comorbidity scores and propensity score-matched comparison based on independent predictors of any-cause mortality. There were 187 patients treated by OR and 156 patients treated by ER. Early procedure-related mortality was 2.6% (9/343), including five OR (2.7%) and four ER (2.6%) patients. Median follow-up was 96 ± 54 months (range, 1-168 months). There were 144 late deaths, most commonly from cardiac causes in 35% (51/144), followed by cancer in 15% (21/144), pulmonary complications in 13% (19/144), and mesenteric ischemia in 11% (16/144). A further 21 patients died from various identifiable causes, and 14 patients (10%) died of unknown causes. Overall, 25 patients (7.3%) died of mesenteric-related causes, including nine early and 16 late deaths (OR, 10/187; 8.0%, and ER, 6/156; 6.4%). Multivariate analysis identified age >80, diabetes, chronic kidney disease (CKD) stage IV or V, and home oxygen therapy as independent predictors (P < .05) of any cause of death. Diabetes and CKD stage IV or V were independently associated with mesenteric-related death (P < .05). Late patient survival at 5 years in the OR and ER groups was 75% ± 4% and 60% ± 9% for low SVS risk (<9), 52% ± 8% and 43% ± 9% for intermediate SVS risk (9-16), and 67% ± 15% and 30% ± 8% for high SVS risk (>16). Using propensity matched scores, 5-year survival was nearly identical for patients treated by OR (60%) or ER (57%; P = .7). Long-term patient survival after mesenteric revascularization was not influenced by type of arterial reconstruction. Age >80 years, diabetes, CKD stage IV or V, and home oxygen were independent predictors of any-cause mortality. Diabetes and CKD stage IV or V were independently associated with mesenteric-related death.

Risk factors contributing to hepatic artery thrombosis following living-donor liver transplantation

This study was carried out to investigate the risk factors contributing to hepatic artery thrombosis in living-donor liver transplantation. Two hundred and twenty-two recipients (113 adults and 109 children) of living-donor liver transplantation were the subjects of this study. The diagnosis of hepatic artery thrombosis was made by color-Doppler ultrasonography and/or hepatic angiography. Parameters for this study were: (1) donor sex, age, and body weight; (2) recipient sex, age, body weight, liver disease, preoperative prothrombin time, and type of arterial reconstruction; and (3) previous liver transplantation. Hepatic artery thrombosis occurred in 12 patients (5.4%) at 3 to 15 days posttransplant. Recipient female sex and metabolic disorder as the original disease were found to be significantly associated with hepatic artery thrombosis. The 5-year patient survival rate in recipients with hepatic artery thrombosis (58.3%) was significantly lower than that in recipients without this complication (84.4%). Female sex and metabolic disease may be factors contributing to hepatic artery thrombosis after living-donor liver transplantation. More intensive anticoagulation therapy for this patient population might decrease the incidence of hepatic artery thrombosis and, thus, posttransplant recipient mortality.

Effect of chronic renal failure on postoperative mortality rate following arterial reconstruction

Abstract Background Chronic renal failure (CRF) is both a risk factor for, and a consequence of, peripheral arterial disease. There is also increasing evidence that patients with CRF have a higher mortality rate following arterial reconstruction, but it is not known whether this is different for aneurysmal or occlusive disease. Methods Over 8 years 1718 consecutive arterial reconstructions performed under the care of one consultant were studied prospectively. Patients were defined as having CRF if at the time of surgery the serum creatinine measured more than 400 μmol 1−1, they were undergoing dialysis or they had received a renal transplant. The in-hospital postoperative mortality rate was compared between patients with and without CRF and analysed according to the urgency as well as the type of arterial reconstruction. Results Sixty-nine patients (4 per cent) undergoing arterial reconstruction over the study period were defined as having CRF. Sixteen (23 per cent) of these died following surgery (myocardial infarct seven, multiple organ failure three, stroke one, mesenteric thrombosis one, paraplegia one, respiratory failure one, pneumonia one, failure to thrive one), in comparison to 120 (7·3 per cent) of 1649 patients without CRF. The mortality rate in patients with CRF was highest in those who underwent urgent/emergency surgery and those who had reconstruction for occlusive disease. Conclusion Patients with CRF have a threefold increase in mortality rate following arterial reconstruction. Patients undergoing infrainguinal bypass are at particular risk and should be carefully selected and counselled.

Outcomes after Lower-Extremity Reconstruction in DRGs 478 and 479

Purpose. To assess outcomes for 21,261 patients in DRGs 478 and 479 hospitalized in Veterans Affairs Medical Centers (VAMCs) during fiscal years 1991–1994. DRGs 478 and 479 contain patients undergoing a variety of vascular procedures including lower-extremity arterial reconstruction.Methods. VA Patient Treatment File (PTF) data were analyzed using Patient Management Category (PMC) software which defined illness severity, patient complexity as defined by PMC count, and calculated resource intensity scale (RIS), a measure of resource utilization, for each admission.Results. In-hospital mortality rate was 3.16% (671/21,261) for all patients. Mortality did not differ between the 14,155 patients who underwent extremity arterial reconstruction (3.22%) and the remaining patients (3.03%). The incidence of ICD-9-CM-coded complications was 20.4% after limb revascularization versus 12.8% for remaining patients (P < 0.001). Length of stay (LOS) was 18.6 ± 17.6 days with versus 10.3 ± 14.5 days without limb revascularization (P < 0.001). As defined in this study, patients who underwent limb revascularization were older (64.1 ± 9.6 vs 62.2 ± 11.0, P < 0.001); had higher illness severity scores (3.63 ± 1.60 vs 2.72 ± 1.72, P < 0.001); were more complex (had higher PMC count: 2.59 ± 1.35 vs 2.54 ± 1.34, P = 0.016); and required utilization of more resources (had higher RIS: 2.16 ± 0.81 vs 1.68 ± 0.76, P < 0.001) than remaining patients. Logistic regression analysis limited to those undergoing extremity revascularization revealed that age, presence of complications, patient complexity, illness severity, and acute arterial thromboembolism were increasingly and independently associated with greater in-hospital mortality. The logistic regression model also showed that the type of arterial reconstruction was related to in-hospital mortality: arterial bypass (ICD-9-CM 39.29) was associated with lower mortality. Outcomes were defined for the subgroup (n = 7728) undergoing arterial bypass (ICD-9-CM 39.29) who were assigned to Patient Management Category 4101, 4113, or 4141: Mortality rates were 2.26, 2.19, and 5.03% for those undergoing elective bypass (n = 3003), urgent bypass (n = 3513), and bypass for gangrene (n = 1212), respectively. Octogenarians did not experience higher mortality rates after elective bypass [1.4% (1/73) vs 2.3% (67/2930), n.s.], but experienced higher mortality rates after urgent bypass [8.6% (8/93) vs 2.0% (69/3420), P < 0.001] and after bypass for gangrene [11.6% (5/43) vs 4.8% (56/1169), P < 0.045].Conclusions. Outcomes for patients in DRGs 478 and 479 who underwent extremity revascularization differed from those who did not. Outcomes varied by the type of arterial reconstruction and its urgency and indication and within selected subpopulations (i.e., octogenarians). DRG-based reimbursement would not be sensitive to these clinically important factors which have a major impact on outcomes and resource utilization.

The impact of microsurgical hepatic arterial reconstruction on the outcome of liver transplantation for congenital biliary atresia

Hepatic artery thrombosis (HAT) after liver transplantation for biliary atresia (BA) is a serious complication that most often leads to retransplantation (re-OLT). The purpose of the present study was: (1) to identify risk factors associated with HAT and (2) to analyze the impact of recently introduced microsurgical hepatic arterial reconstruction (MHR) on the incidence of HAT, subsequent need for re-OLT, and patient survival. A retrospective review of 194 patients transplanted for BA was performed. One hundred and sixty-six patients (group 1) underwent conventional arterial reconstruction and 28 (group 2) had MHR. Actuarial survival for patients with HAT was significantly worse than for patients without HAT at 1, 2, and 5 years (71%, 61%, and 57% versus 85%, 85%, and 85%, P = 0.0007). Stepwise logistic regression analysis revealed that the risk of HAT correlated best with the type of arterial reconstruction (P = 0.007) followed by pretransplant bilirubin concentration (P = 0.04) and the number of acute rejection episodes (P = 0.03). In group 1, 32 patients developed HAT (19%), and of these, 18 underwent re-OLT for HAT. No patient in group 2 developed HAT (P = 0.006 versus group 1). One-year actuarial patient survival was 81% in group 1 and 100% in group 2 (P = 0.02). In OLT for BA, (1) the predominant risk factor for HAT is the technique of arterial reconstruction, and (2) MHR markedly reduces the incidence of HAT and the need for re-OLT while improving patient survival.

Anastomotic aneurysms—an underdiagnosed complication after aorto-iliac reconstructions

Anastomotic aneurysms (AA) are recognised as a long-term complication of aorto-iliac (AI) reconstructions and in the literature an incidence of 2-8% is reported. From our own experience we suspected a much higher frequency of this complication and started a follow-up study in order to establish: 1. The actual incidence of AA and 2. The value of various methods of investigation in the diagnosis of this condition. During a 4-year-period (1977-1980) 303 patients (PTS) underwent an AI reconstruction and were the subject of this study. During the mean 8-year (range 6-10 years) follow-up period 158 patients died (52%). The 145 survivors underwent physical examination (PE), ultrasonography (US), and intravenous digital subtraction angiography (i.v. DSA). Complete data were available from 122 patients. The incidence of AA in the 303 patients of the original group, established by routine follow-up examination was 16/303 (5.1%). However, the incidence of AA in the 122 patients in this study was 36/122 (29.5%). These 36 patients developed 52 AA which were located at the following anatomic sites: aortic anastomoses 3/115 (2.6%), iliac artery anastomoses 18/146 (12.3%), femoral artery anastomoses 31/70 (44.3%). Fourteen of the 52 AA (33%) were operated on and the diagnosis was confirmed. The patient characteristics (age distribution, type of arterial reconstruction, indication for operation) of the group of 122 patients were not significantly different from the original group of 303 patients. Intravenous DSA proved to be the most reliable diagnostic test. Physical examination was relatively inaccurate when compared with imaging tests with a 37% false positive and 67% false negative rate.(ABSTRACT TRUNCATED AT 250 WORDS)