Reconstructive Vascular Surgery Research Articles

Vascular Graft Infections, Mycotic Aneurysms, and Endovascular Infections: A Scientific Statement From the American Heart Association.

### Background The use of synthetic material for reconstructive vascular surgery was first reported during the early 1950s. Infection involving vascular graft prostheses is an infrequent but devastating complication of reconstructive vascular graft surgery and is associated with a high morbidity and, in some situations, mortality. Improvements in surgical techniques and graft design, including the use of native venous or arterial tissue, have reduced the frequency of infection and severity of complications from vascular graft infection (VGI). However, these advances have also led to more frequent vascular graft procedures occurring in a patient population with multiple underlying comorbidities that would have previously disqualified them as candidates for vascular reconstructive surgery. Underlying comorbidities, such as diabetes mellitus or immune compromise, increase the risk of infection and serious infection-related complications. The major complications of VGI include sepsis, amputation, disruption of infected anastomotic suture line with rupture or pseudoaneurysm formation, embolization of infected thrombi, reinfection of reconstructed vascular grafts, enteric fistulae to the small or large bowel, bacteremic spread of infection to other sites, and death. VGIs can be categorized broadly into those that occur in an extracavitary location, primarily in the groin or lower extremities, or in an intracavitary location, primarily within the abdomen or less commonly within the thorax. ### Frequency The frequency of VGI depends on the anatomic location of the graft. The infection rate is 1.5% to 2% for most extracavitary grafts and as high as 6% with vascular grafts in the groin.1–9 For intracavitary grafts, the infection rate is ≈1% to 5%.1–6 Graft infection is most common after emergency procedures and after reoperation.1–4,10 Aortic graft erosion or fistulous communication into the duodenum or other areas of the bowel reportedly occurs in 1% to 2% of patients after aortic reconstruction.11, …

Role of Operative Lumbar Sympathectomy in Patients with Critical Lower Limb Ischemia not Amenable to Vascular Reconstructive Surgery

Role of Operative Lumbar Sympathectomy in Patients with Critical Lower Limb Ischemia not Amenable to Vascular Reconstructive Surgery

Unusual variability in the branching pattern of femoral artery and its radiological and surgical significance

The femoral artery is a continuation of external iliac artery below inguinal ligament. The knowledge of variations in the branching pattern of femoral artery is very important for vascular surgeons and intervention radiologists. Variations which involve the femoral, profunda femoris and circumflex femoral arteries are important in vascular reconstructive surgeries, in surgical intervention for embolism, catheterization procedures and in raising myocutaneous graft with pedicle. We report a case of unusual origins of medial and lateral circumflex femoral arteries directly from femoral artery. Accurate knowledge of anatomical variations regarding origin of medial and lateral circumflex femoral arteries is important in present modern era of interventional radiology.

Reconstructive vascular surgery and the extent of tissue damage due to diabetic foot ulcers relates to risk of new ulceration in patients with PAD

There is limited information regarding new ulceration following the healing of ischaemic foot ulcers in diabetic patients. Our aim is to study new ulcerations in the same foot as the previous ulcer(s) in patients with diabetes and severe peripheral artery disease (PAD). Patients with diabetes and severe PAD who healed from previous ulcer(s) (Wagner grade 1-5, at or below the ankle), were recruited for the prospective study from the time of healing of their ulcer. Patients were followed up regarding new ulceration, and their treatments and ulcer status noted either directly or on examination of medical records. We analysed the data on 602 patients with diabetes and severe PAD with healed foot ulcers, either primarily (n=443, 74%) or after minor amputation (n=159, 26%). Of these 51% (n=305) had revascularisation before healing from the previous ulcer, 34% (n=202) developed a new ulcer on the same foot within 15 months (range 0-106). Amputation was required by 22% (n=45) of patients, with a new ulcer on the same foot. The median survival time of all patients (n=602) was 54 months. By regression analysis, a low maximal Wagner grade for the previous ulcer and reconstructive vascular surgery was related to a decreased risk of developing new ulcers in the same foot. Patients with diabetes and ischaemic foot ulcers have a high-risk for developing new ulcers and amputation in the same foot after healing. The extent of tissue involvement in the previous ulcer and reconstructive vascular surgery affected the risk for development of new ulcers.

Biofunctionalization via flow shear stress resistant adhesive polysaccharide, hyaluronic acid-catechol, for enhanced in vitro endothelialization

We report a single-step method for achieving in vitro endothelialization using a water-resistant adhesive polysaccharide, hyaluronic acid (HA). Introduction of adhesive properties is inspired by the catechol chemistry utilized in marine mussels, in which bioactive hyaluronic acid is chemically modified into hyaluronic acid-catechol (HA-catechol). Quantification of cell adhesiveness to HA-catechol coated substrate was performed with microfluidic device-based adhesion assay under shear forces. The HA-catechol exhibited enhanced ability of surface binding under flow shear force condition compared to unmodified HA. HA-catechol was able to retain the adhered endothelial cells under fluid shear stresses up to 150dyn/cm2, which is above the physiological condition in human vascular system. This is the first study demonstrating utility of the adhesive force of catechol-tethered polymers under continuous shear force environments such as microfluidic devices. The HA-catechol compound developed herein could provide a straightforward strategy for improving stability in surface retention and preventing substantial tissue damage from the fluctuating blood flow after vascular reconstructive surgery.

The Clinical Usefulness of Nuclear Medicine Techniques in the Diagnosis of Vascular Graft Infections

The infection of a vascular prosthesis (VGI) is the most serious complication in prosthetic vascular reconstructive surgery, burdened by a high rate of mortality and morbidity. The treatment of a VGI, in most cases, consists of its surgical removal, and therefore an accurate diagnosis of the infection, is of paramount importance in clinical practice since false-positive results may lead to unnecessary major surgery whereas false-negative results are related with high-risk morbidity. Furthermore, early diagnosis of infection permits a wider range of therapeutic options and a less aggressive surgical approach. On the basis of the documents and abstracts published in the last 25 years, the authors analyze and discuss the contribution of nuclear medicine in the management of these infections, evaluating the reliability of scintigraphy with labeled leukocytes, other gamma-emitting radiopharmaceuticals, PET and PET / CT with 18F-Fluorodeoxiglucose. Keywords: 18F-FDG, 99mTc-labelled leucocytes, imaging, PET / CT, SPECT / CT, vascular graft infection.

Program and AbstractsThirty-fourth Annual Meeting of the Surgical Infection SocietyBaltimore, MarylandMay 1–3, 2014

Program and AbstractsThirty-fourth Annual Meeting of the Surgical Infection SocietyBaltimore, MarylandMay 1–3, 2014

Construction of Tissue-Engineered Small-Diameter Vascular Grafts in Fibrin Scaffolds in 30 Days

Tissue-engineered small-diameter vascular grafts have been developed as a promising alternative to native veins or arteries for replacement therapy. However, there is still a crucial need to improve the current approaches to render the tissue-engineered blood vessels more favorable for clinical applications. A completely biological blood vessel (3-mm inner diameter) was constructed by culturing a 50:50 mixture of bovine smooth muscle cells (SMCs) with neonatal human dermal fibroblasts in fibrin gels. After 30 days of culture under pulsatile stretching, the engineered blood vessels demonstrated an average burst pressure of 913.3±150.1 mmHg (n=6), a suture retention (53.3±15.4 g) that is suitable for implantation, and a compliance (3.1%±2.5% per 100 mmHg) that is comparable to native vessels. These engineered grafts contained circumferentially aligned collagen fibers, microfibrils and elastic fibers, and differentiated SMCs, mimicking a native artery. These promising mechanical and biochemical properties were achieved in a very short culture time of 30 days, suggesting the potential of co-culturing SMCs with fibroblasts in fibrin gels to generate functional small-diameter vascular grafts for vascular reconstruction surgery.

Anatomical variants of profunda femoris artery : among cadavers from South India

Abstract Background: The profunda femoris artery (PFA) is a branch of femoral artery which plays an important role in the arterial supply of the thigh. An extensive knowledge of the branching pattern and relations are necessary for clinicians to prevent any iatrogenic damage to these blood vessels and the surrounding structures in vascular reconstructive surgeries. Objective: To study the direction of origin of PFA from femoral artery and measure DIP- the distance between the origin of PFA from femoral artery to midpoint of inguinal ligament. Materials and Methods: Forty six femoral triangles (23 on right & 23 on left side) were dissected and studied in embalmed cadavers available in dissection hall of K. S. Hegde Medical Academy, Mangalore, India over a period of two years from July 2011 to July 2013. These cadavers were of South Indian origin. The direction of origin of PFA from femoral artery was noted. The DIP was measured using Vernier caliper. Results: The direction of origin of the PFA in majority of the cases was found to be from the posterolateral side (65.22%) of femoral artery. The DIP varies from 25 to 50 mm on the right and 24 to 60 mm on the left side. In 50 % of the cases, the DIP was in the range of 41 to 50 mm on both the sides. Conclusion: The anatomical data obtained here is of importance for surgeons and radiologists for procedures centred on the PFA and in vascular reconstructive surgeries involving the groin.

Anatomical variants of profunda femoris artery : Among cadavers from South India

Background: The profunda femoris artery (PFA) is a branch of femoral artery which plays an important role in the arterial supply of the thigh. An extensive knowledge of the branching pattern and relations are necessary for clinicians to prevent any iatrogenic damage to these blood vessels and the surrounding structures in vascular reconstructive surgeries. Objective: To study the direction of origin of PFA from femoral artery and measure DIP- the distance between the origin of PFA from femoral artery to midpoint of inguinal ligament. Materials and Methods: Forty six femoral triangles (23 on right & 23 on left side) were dissected and studied in embalmed cadavers available in dissection hall of K. S. Hegde Medical Academy, Mangalore, India over a period of two years from July 2011 to July 2013. These cadavers were of South Indian origin. The direction of origin of PFA from femoral artery was noted. The DIP was measured using Vernier caliper. Results: The direction of origin of the PFA in majority of the cases was found to be from the posterolateral side (65.22%) of femoral artery. The DIP varies from 25 to 50 mm on the right and 24 to 60 mm on the left side. In 50 % of the cases, the DIP was in the range of 41 to 50 mm on both the sides. Conclusion: The anatomical data obtained here is of importance for surgeons and radiologists for procedures centred on the PFA and in vascular reconstructive surgeries involving the groin.

Formation Of Superficial Palmar Arch:A Cadaveric Study With Its Clinical Significances

The vasculature of the hand has been a topic of anatomical interest because of wide range of variations in the formation and distribution of palmar arches. In the present study we have emphasized on the varying pattern of the formation and branching pattern of the superficial palmar arch (SPA) in cadaveric human hands. The study was conducted in 42 formalin fixed human cadaveric hands and different presentations were noted. The classic formation of the SPA was noted in 76.6% of the specimens and mostly on the right hand. The other variants noted were SPA completed by the first dorsal metacarpal artery and SPA formed between median and ulnar artery. Incomplete SPA ending in the thenar muscles and an abrupt end between the index and middle finger were also noted in the present study. The existence of both common and rare anatomic variations in the formation of superficial palmar arch as well as the absence of collateral circulation between ulnar and radial arteries necessitates the proper knowledge of vasculature of the hand in order to avoid or minimize the risk of complications during vascular surgeries or reconstructive surgeries in the hand.

Successful treatment of suprasellar tumors associated with poor brain blood perfusion by severe intracranial arterial stenosis: two case reports

BackgroundTreatment strategy to prevent perioperative cerebral infarction in patients with asymptomatic severe stenosis of the internal carotid artery is not fully established.Case presentationTwo patients were treated for skull base tumor in the presence of severe stenosis of the internal carotid artery, unilateral in one patient and bilateral in the other patient. Both patients were asymptomatic but had reduced vascular reserve capacity. The extended transsphenoidal approach was planned avoiding the low perfusion pressure region, with only conventional methods of maintaining blood pressure and PaCO2 rather than performing prophylactic vascular reconstruction surgery, and successful tumor removals were achieved without causing further neurological or radiological deficits.ConclusionIf the surgical route is planned to avoid the distribution of stenotic vessels and low perfusion pressure, prophylactic vascular reconstruction surgery would be unnecessary. Although more experiences based on sub-classified etiology for internal carotid artery stenosis are required, various types of operations including intracranial-extracranial vascular surgery might be justified based on this principle.

OP163: Optimal application of reconstructive microsurgery in a high volume tertiary referral cancer centre

Background Although the state of art free flap reconstruction of oral defects is not cost effective in a high volume low resource set up with scarcity of trained hands. Patients and methods Thirty-five consecutive cases of oncologic head and neck micro vascular reconstructions at the Regional Cancer Centre, Trivandrum, between October 2004 and October 2011 were studied prospectively for the flap viability, cosmesis, function (speech and swallowing) and locoregional recurrence. Free flap reconstruction was planned in all these cases either because it was the only available option or because it was far superior to the conventional option. Results There were 25 males and 10 female patients, the ages of whom ranged from 16 to 75 years with a mean ±S.D of 46 ± 14 years. Twenty-five cases were squamous cell carcinomas, two were soft tissue sarcomas, one was an intraosseous carcinoma one was a chondrosarcoma two were osteosarcomas three cases were recurrent ameloblastomas and one was a recurrent basal cell carcinoma. Site distribution and the flap chosen for reconstruction and the type of neck dissections done were as follows. (See Table 1 .) Free fibular flap showed the highest success rate (100%) followed by radial forearm (77%) and ALT (50%). The follow up period ranged from 2 to 59 months with a mean of 19.6 months and median of 14 months. The operating time ranged from 255 to 495 min with a mean 398 ±SD of ±52 min. Twenty-nine cases were uneventful and 6 flaps failed. None of these patients required prophylactic tracheostomy and only one of the failures required a second flap. Six patients either recurred locoregionally or had metachronous second primary. (See Table 2 .) Conclusion Adequate training and optimal application are the key factors determining success in micro vascular reconstructive surgery in a low resource high volume cancer centre.

Opportunities of improvement in the management of pancreatic and periampullary tumors

Objective. The first objective of the present study was to identify opportunities of improvement for clinical practice, assessed by local quality indicators, then to analyze possible reasons why we did not reach defined treatment quality measures. The second objective was to characterize patients, considered unresectable according to present criteria, for future arrangement of interventional studies with improved patient selection. Material and methods. Prospective observational cohort study from October 2008 to December 2010 of patients referred to the authors' institution with suspected pancreatic or periampullary neoplasm. Results. Of 330 patients, 135 underwent surgery, 195 did not, 129 due to unresectable malignancies. The rest had benign lesions. Perioperative morbidity rate was 32.6%, mortality 0.7%. Radical resection (R0) was obtained in 23 (41.8%) of 55 patients operated for pancreatic adenocarcinoma and 6.3% underwent reconstructive vascular surgery. Diagnostic failure/delay resulted in unresectable carcinoma, primarily misconceived as serous cystic adenoma in two patients. One resected lesion turned out to be focal autoimmune pancreatitis. One case with misdiagnosed cancer was revised to be a pseudoaneurysm. Palliative treatment was offered to 144 patients with malignant tumors, 62 due to locally advanced disease and all pancreatic adenocarcinomas. Conclusions. Quality improvement opportunities were identified for patient selection and surgical technique: Too few patients underwent reconstructive vascular surgery. The most important quality indicators are those securing resectional, radical (R0) surgery. Altogether 143 patients (57.9%) of those with malignant tumors were found unresectable, most of these patients are eligible for inclusion in future interventional studies with curative and/or palliative intention.

A Case of Large Recurrent Perigraft Seroma after Axillobifemoral Bypass

Introduction Perigraft seroma is an uncommon complication of vascular reconstructive surgery. We report a case of a large recurrent seroma related to an axillobifemoral bypass. Case report A 79-year-old male patient developed a large seroma in his left flank and suprapubic region after an axillobifemoral bypass. The seroma was so large that it prevented the patient from bending. It recollected twice after drainage, which led to the decision to remove the graft and to replace it with a different synthetic material. Discussion Seromas are suspected when there is a sterile mass in relation to a bypass graft. To our knowledge, this is one of the larger seromas related to axillobifemoral bypass documented in published literature, reaching a size such that it interfered with the patient's physical functioning.

Ileocolon Interposition Graft Following Surgery for Gastro-esophageal Junction Adenocarcinoma

The stomach remains the most preferred esophageal substitute following esophagectomy for cancer [1]. However in circumstances where the stomach is not available due to involvement by the cancer, such as in our patient, or due to prior surgery, a few other options are still available. While the jejunum is suitable to reconstruct total gastrectomy and distal esophagectomy at or below the level of pulmonary hilum, its use when more of esophagus is resected is complicated by the need for micro vascular reconstructive surgery [2]. In such a scenario, the colonic conduit is the preferred substitute because of its consistent blood supply, long length and acid resistance [2]. Traditionally, the left colonic graft is more often used, but there is an increasing trend towards using right sided colonic or ileo-colonic conduits. We present a report wherein an ileo-colon interposition graft based on middle colic artery was used to reconstruct the Gastro-Intestinal tract following subtotal esophagectomy and total gastrectomy.

Takayasu’s Arteritis: An Uncommon Cause of Renal Artery Stenosis and Therapeutic Considerations

Takayasu’s arteritis is a rare disorder characterized by granulomatous and necro-inflammatory disease of the aorta and its major branches. Its etiology remains unknown. We report a young woman with Takayasu’s arteritis affecting the aortic arch, carotid, mesenteric, celiac and bilateral renal arteries resulting in severe hypertension, unilateral renal atrophy and renal insufficiency. The immunosuppressive therapy did not halt the progression of her vascular disease, which required revascularization procedures on numerous occasions. Here, the clinical manifestations and histopathological features of Takayasu’s arteritis are reviewed. In addition, the available medical treatment options including glucocorticoids, cytotoxic agents and TNF-alpha inhibitors are discussed. Furthermore, current revascularization procedures such as percutaneous transluminal angioplasty and reconstructive vascular surgery in the treatment of occlusive vasculopathy due to Takayasu’s arteritis are discussed. Although the prognosis of this debilitating disease has improved over the past two decades, a better understanding of its etiology and pathogenesis will facilitate the discovery of effective target-specific treatment strategies with a narrow adverse effects profile.

Takayasu’s Arteritis: A Review Article

We selected the medicine research papers in English language published from the year 2005 to the date to determine the clinical significance of Takayasu’s arteritis (TA) and to review the literature available on this condition. TA is a world-wide, chronic inflammatory disease of unknown etiology. It is more prevalent in Asian countries. There are no specific laboratory tests to diagnose TA as it usually presents with non-specific symptoms such as fatigue, fever, arthralgia, weight loss, malaise, weakness and vision changes. Angiographic imaging is considered to be the gold standard investigation in diagnosing TA. Steroids with subsequent tapering doses are the mainstay of medical treatment; however, for addressing the refractory cases additional therapy becomes necessary. Reconstructive vascular surgery is limited to the severe and irreversible stenotic lesions where surgery becomes inevitable.

The evaluation of the effectiveness of Tachosil in the treatment of lymphorrhea of the postoperative wound in the selected group of patients, after vascular reconstructive surgeries – preliminary report

Lymphorrhea of a postoperative wound after vascular reconstructive surgeries does not occur frequently but it accounts for a major complication. It should be brought to attention that during the intraoperative period it is impossible to diagnose any damages within the lymphatic system of the operated area. Additionally, the treatment of lymphorrhea with thermal abrasion does not usually bring the desired outcome. Therefore, the extended time of the postoperative wound treatment with the lymphatic drainage constitutes a standard method in such cases. The aim of the study was to evaluate the effectiveness of Tachosil surgical patch in the treatment of lymphorrhea of the postoperative wound in a selected group of patients who have undergone vascular reconstructive surgeries. Additionally, the aim of the study was to analyze the results and draw conclusions pertaining to the validity and effectiveness of the treatment with the use of Tachosil surgical patch. The observed group included 10 patients with lymphorrhea developed during the postoperative period. 6 of the observed patients have undergone the vascular reconstructive surgery with the implantation of the vascular prosthesis (distal femoropopliteal reconstruction bridge - 3 patients; iliofemoral reconstruction bridge - 1 patient; angioplasty of the common femoral artery (CFA) with the use of the prosthetic patch - 1 patient; the implantation of the bifurcated (type Y) aortofemoral prosthesis - 1 patient). The remaining patients in the observed group have undergone the restoration of patency of the CFA. Additionally, 1 patient has undergone the resection of the pseudo aneurysm in the distal part of the iliofemoral prosthesis. The vascular reconstructive surgery required the denudation and isolation of the common femoral artery from the surrounding tissue as a step 1. The persisting lymphorrhea of the postoperative wound, in the volume of more than 200 ml per day during the first 3 postoperative days, indicated the necessity for the inguinal wound revision. In addition, Tachosil surgical patch was applied at that time. The drain was placed over Tachosil patch. Complete stop of lymphorrhea was shorter by 4.87 days in patients treated with the use of Tachosil in comparison to control group. These patients also had an average hospitalization time shorter by 3.88 days than patients in the control group. Early intervention in the cases of lymphorrhea of the postoperative wound allows planning and conducting successful treatment. The use of Tachosil surgical patch in the treatment of lymphorrhea of the postoperative wound shortens the treatment and hospitalization periods. The use of Tachosil in the treatment of postoperative lymphorrhea appeared to be significantly more effective than the standard drainage method of treatment. Results obtained through this study pave the way for the research on other possible applications of Tachosil in the cases of lymphorrhea after vascular reconstructive surgeries.

Ca2+ Signalling in Damaged Endothelium and Arterial Remodelling: Do Connexin Hemichannels Provide a Suitable Target to Prevent In-stent Restenosis?

A monolayer of endothelial cells (ECs) lines the lumen of blood vessels and forms a multifunctional transducing organ that regulates cardiovascular homeostasis. Disruption of endothelial integrity, as a result of either angioplasty or stent deployment, may produce a late in-stent restenosis and limit the beneficial outcome of reconstructive vascular surgery. Restoration of endothelial lining requires spreading, migration and proliferation of ECs nearby the lesion site. Intracellular Ca2+ signalling plays a major regulatory role in stimulating wound healing, however, the mechanism whereby injury increases Ca2+ levels at the wound edge is still unclear. The analysis of Ca2+ signals elicited by scraping an endothelial monolayer in vitro suggested the involvement of intracellular Ca2+ release from InsP3-sensitive stores and Ca2+ entry through unknown ion channels in the plasma membrane. Recent studies carried out on excised rat aorta highlighted a novel role for connexin hemichannels (CxHcs) in mediating Ca2+ entry in injured endothelium. Understanding the signal transduction pathway leading to EC activation is likely to provide novel targets to design therapeutic applications aiming to restore endothelial integrity and treat cardiovascular diseases. Therefore, alternative drug-eluting stents might be devised to trigger CxHc opening and reduce in-stent restenosis following vascular regenerative surgery.