Vein Anastomosis Research Articles

Increasing the success of reverse sural flap from proximal part of posterior calf for traumatic foot and ankle reconstruction: Patient selection and surgical refinement

In this report, we present our experience on the use of the reverse sural flap for traumatic foot and ankle reconstruction. The patient selection and surgical refinement are discussed. From 2007 to 2010, 11 consecutive patients underwent modified reverse sural flap at the Chang Gung Memorial Hospital. The defects were located at the ankle (three cases), foot (two cases), and heel (six cases). Particular attention was paid to precise patient selection and surgical refinements. Patient selection was based on the lower limb vascular status by palpable distal pedal pulses and ankle brachial index ranging from 0.9 to 1.2. Surgical techniques were refined as precisely locating the perforators of peroneal artery, placing the skin paddle in upper third of leg for a distal region coverage, designing a 7-cm-wide adipofascial pedicle with a 2 cm skin paddle on it, preserving the mesentery structure of sural nerve and concomitant artery with or without including gastrocnemius muscles cuff, no tunneling when inset this flap and supercharging with lesser saphenous vein whenever needed. All the flaps survived completely. Only one patient required immediate anastomosis of lesser saphenous vein to local vein around defect in order to relieve the venous congestion during operation. Patients felt diminished but adequate recovery of sense of touch and temperature at the flap. Following the precise patient selection and surgical refinements, the modified reverse sural flap seemed to be a reliable and effective local flap for reconstruction of the soft tissue defects on ankle and foot.

Consensus on Timing of Intervention for Common Congenital Heart Diseases: Part II - Cyanotic Heart Defects

The purpose of this review/editorial is to discuss how and when to treat the most common cyanotic congenital heart defects (CHDs); the discussion of acyanotic heart defects was presented in a previous editorial. By and large, the indications and timing of intervention are decided by the severity of the lesion. While some patients with acyanotic CHD may not require surgical or transcatheter intervention because of spontaneous resolution of the defect or mildness of the defect, the majority of cyanotic CHD will require intervention, mostly surgical. Total surgical correction is the treatment of choice for tetralogy of Fallot patients although some patients may need to be palliated initially by performing a modified Blalock-Taussig shunt. For transposition of the great arteries, arterial switch (Jatene) procedure is the treatment of choice, although Rastelli procedure is required for patients who have associated ventricular septal defect (VSD) and pulmonary stenosis (PS). Some of these babies may require Prostaglandin E1 infusion and/or balloon atrial septostomy prior to corrective surgery. In tricuspid atresia patients, most babies require palliation at presentation either with a modified Blalock-Taussig shunt or pulmonary artery banding followed later by staged Fontan (bidirectional Glenn followed later by extracardiac conduit Fontan conversion usually with fenestration). Truncus arteriosus babies are treated by closure of VSD along with right ventricle to pulmonary artery conduit; palliative banding of the pulmonary artery is no longer recommended. Total anomalous pulmonary venous connection babies require anastomosis of the common pulmonary vein with the left atrium at presentation. Other defects should also be addressed by staged correction or complete repair depending upon the anatomy/physiology. Feasibility, safety and effectiveness of treatment of cyanotic CHD with currently available medical, transcatheter and surgical methods are well established and should be performed at an appropriate age in order to prevent damage to cardiovascular structures.

Living donor liver transplantation with alternative porto‐left gastric vein anastomosis in patients with post‐Kasai extrahepatic portal vein obstruction

EPVO is a common cause of prehepatic portal hypertension in pediatric patients and sometimes results in cavernous transformation of the PV. We herein present the cases of two patients who underwent LDLT for EPVO with post-Kasai biliary atresia. PV reconstruction was performed with a porto-left gastric vein anastomosis. The patient who underwent PV reconstruction using an interposition vein graft is doing well without surgical complications, whereas PV anastomotic stenosis was detected three months after LDLT in the patient who did not receive an interposition vein graft. The availability of vein grafts is limited in the LDLT setting. In such cases, performing PV reconstruction with varicose veins using interposition vein grafts is a feasible and valuable alternative option for obtaining a sufficient portal blood flow. Our experiences suggest that using interposition vein grafts may be appropriate for preventing the anastomotic stenosis caused by the fragility of varicose veins.

Trasplante renal en bloque de donantes pediátricos

Objetivo: Determinar la aceptación de ambos riñones de donantes pediátricos para utilizarlos como trasplante renal en bloque. Material y Métodos: La edad de los seis donantes varió entre 14 meses y 10 años. La causa de muerte fue el traumatismo encefalocraneano. La edad de los seis receptores osciló entre 15 y 48 años con peso menor de 50 kg. Ambos riñones fueron removidos en bloque. La técnica operatoria de los trasplantes consistió en la anastomosis término lateral del segmento aórtico y vena cava inferior del donante a los vasos ilíacos del receptor; ambos uréteres fueron anastomosados por separado a la vejiga. El implante fue localizado en una de las fosas ilíacas. Resultados: Los injertos en bloque funcionaron inmediatamente. Cuatro de los seis receptores cursaron con función renal adecuada a cuatro años promedio de seguimiento. Uno de los injertos en bloque se perdió por rechazo vascular severo y otro por indisciplina a la medicación inmunosupresora. Las series ecográficas de los riñones revelaron incremento de tamaño hasta en 55% de su dimensión original al tercer mes del trasplante. Conclusión: Se recomienda que los riñones procedentes de donantes menores de tres años de edad sean utilizados como trasplante en bloque y riñones de donantes mayores de tres años como trasplante renal simple. Se demuestra que es posible trasplantar exitosamente riñones en bloque de niños muy pequeños en receptores mayores, según experiencia inédita en nuestro medio.

Hyaluronic Acid Viscoelastic Medium as an Aid for Microsurgical Venous Anastomoses

The thin-walled structure of veins leads them to stay collapsed during anastomoses, thereby the incidence of technical failures is more common than arterial anastomoses. In order to overcome this problem, we are introducing the use of viscoelastic material based on our experience on rats. Six rats were used in order to study the technical feasibility of the viscoelastic material during microsurgical vein anastomosis. End-to-end anastomoses were performed on rat jugular veins using 0.5-1 mL of the viscoelastic medium applied to the ends of the veins and surgical field under ×30 operating microscope magnification. Then 1.8% (n:3) and 3.0% (n:3) hyaluronic acid was used as a viscous medium in order to keep the vein lumens open during anastomosis. In conclusion, we have found that 3.0% hyaluronic acid viscoelastic medium facilitates microvenous anastomosis in rat. Studies involving human practice are needed for further evaluation of this technical refinement.

Distal anastomotic patency of the Cardica C-PORT® xA system versus the hand-sewn technique: a prospective randomized controlled study in patients undergoing coronary artery bypass grafting†

The C-Port® Distal Anastomosis Systems (Cardica, Inc., Redwood City, CA, USA) demonstrated favourable results in feasibility trials. However, distal vein anastomoses created with the C-Port® or C-Port xA® system have never been compared with hand-sewn distal vein anastomoses. The objective of this study was to compare distal end-to-side anastomoses facilitated with the C-Port xA® System with the traditional hand-sewn method. This single-centre prospective randomized controlled study comprised 71 patients (device group n = 35, control group n = 36) who underwent primary elective coronary artery bypass grafting between June 2008 and April 2011. The primary study end-point was 12-month distal anastomotic patency, which was assessed with prospective ECG-gated 256-multislice computed tomographic coronary angiography using a step-and-shoot scanning protocol. For the primary end-point, a per-protocol analysis was used. In the device group, four (11%) anastomoses were converted to hand-sewn anastomoses, and additional stitches to achieve haemostasis were necessary in 22 (76%) patients. There was no hospital mortality in either group. During the 12-month follow-up, a single death occurred in the Device group and was unrelated to the device. Twenty-nine patients in the device group and 32 in the control group completed 12-month CT coronary angiography. The overall patency of 160 studied distal vein graft anastomoses was 93%. Comparison of the end-to-side target anastomosis showed 12-month patencies of 86 and 88% in the device group and the control group, respectively. According to these preliminary results and despite the limited number of patients, the use of the C-Port xA® System is safe enough to perform distal end-to-side vein graft anastomosis, with respect to 12-month end-to-side distal venous anastomotic patency. Although there are some technical challenges with this device, the incidence of complications is comparable to the traditional hand-sewn technique.

Clinical usefulness of portal venous stent in hepatobiliary pancreatic cancers

Treatment options for patients with portal vein (PV) stenosis or occlusion after surgery are limited. The purpose of this study was to investigate the efficacy and safety of PV stent placement in patients with portal vein occlusion or stenosis after radical operation for hepatobiliary pancreatic malignant tumour. We retrospectively reviewed the records of 59 patients who underwent portal venous stent placement at the Asan Medical Center, Seoul, Korea, for PV stenosis or occlusion between February 2008 and February 2012. Stents were placed in the portal venous system across stenotic (n = 47) and occlusive (n = 12) lesions after percutaneous transhepatic portography. Reasons for stent placement were tumour recurrence (n = 30), portal vein resection and anastomosis (n = 18) and post-operative inflammatory changes (n = 11). Pressure gradients (superior mesenteric vein, main PV) decreased immediately after stent placement, from 10.5 mm Hg ± 4.4 (standard deviation) to 2.5 mm Hg ± 2.6 (P < 0.0001). Liver function was improved post-stenting (P < 0.05). The median time between the original surgery and stent placement was 16 (1-137) days in the vascular-orientated group and 306 (13-3703) days in the tumour recurrence group (P < 0.0001). Transient fever developed in 11 patients, but resolved in 2-5 days. Stents were occluded in 15 of the 59 patients (25.4%). PV stent placement is a safe choice, has an acceptable success rate and provides marked relief from portal hypertension due to portal vein occlusion or stenosis after hepatobiliary pancreatic surgery. Liver function data are also improved after portal venous stent placement.

Middle hepatic vein to middle hepatic vein anastomosis in right lobe living donor liver transplantation

Middle hepatic vein to middle hepatic vein anastomosis in right lobe living donor liver transplantation

Feasibility of laparoscopic orthotopic kidney transplantation: Initial research with a pig model

The objective of this study was to investigate the feasibility of laparoscopic orthotopic kidney transplantation. This study involved bilateral laparoscopic nephrectomy in pigs. One of 2 kidneys harvested from the first or second nephrectomy was chosen as the donor kidney to be transplanted to the left or right side in the second nephrectomy position. Eight laparoscopic orthotopic kidney transplantations were performed. The mean venous anastomotic time was 70 minutes (45-108 minutes). The mean arterial anastomotic time was 31 minutes (23-45 minutes). Three pigs received life-supporting auto-renal allografts. Their serum creatinine levels were 163, 285, and 440 µmol/L (baseline: 133 µmol/L), respectively, at postoperative day 7. One died of a possible anesthetic overdose immediately after the operation. Four pigs died at postoperative days 2, 3, 4, and 4. Of 8 completed laparoscopic orthotopic kidney transplantations, 6 had autopsy-proven reliable artery and vein anastomoses. Histopathologic examination of the autografts demonstrated normal renal architecture in 1 survival, and acute tubular necrosis in the remaining 7 (stenosis in one and arterial thrombus in another). Our study reinforces the feasibility of laparoscopic orthotopic kidney transplantation in pigs. This study comprised only initial practices; further practice is needed to refine the surgical procedures and decrease surgical complications in laparoscopic orthotopic kidney transplantation.

Long-term management of the successful adult liver transplant: 2012 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation

Michael R. Lucey, Norah Terrault, Lolu Ojo, J. Eileen Hay, James Neuberger, Emily Blumberg, and Lewis W. Teperman Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI; Gastroenterology Division, Department of Medicine, University of California San Francisco, San Francisco, CA; Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI; Mayo Clinic, Rochester, MN; Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom; Division of Infectious Diseases, University of Pennsylvania School of Medicine, Philadelphia, PA; and Department of Surgery, NYU Transplant Associates, New York, NY

Fingertip reconstruction of the thumb using the ulnodorsal neurocutaneous vascular flap with anastomosis of the vein and nerve

Objective To introduce an improved method of fingertip reconstruction of the thumb.Methods The reversed ulnedorsal neurocutaneous vascular flap was transferred to cover fingertip defects of the thumb in 19 cases.Nerve and venous anastomosis was done to improve blood drainage and to restore sensation of the flaps.Results All 19 flaps survived.Postoperative follow-up of 6 to 24 months showed satisfactory appearance and good function of the thumbs.Conclusion Transfer of reversed ulnodorsal neurocutaneous vascular flap with nerve and venous anastomosis is an optimal choice in the treatment of finger pulp defects of the thumb. Key words: Thumb; Surgical flaps; Transplantation

Treatment of nutcracker syndrome with spermatic vein ligation and iliac vein anastomosis: Case report of three cases

Three patients with nutcracker syndrome (NCS) were enrolled in the study. Their clinical symptoms mainly included proteinuria and serious varicocele. Color Doppler ultrasound and computed tomography showed that the patients had constricted abdominal aortas, reduced superior mesenteric artery angles, and thinned left renal veins. Patients then underwent left spermatic vein ligation and iliac vein anastomosis. They were checked three months after their operation, and results showed that their sperms were improved and their proteinuria disappeared. The color Doppler ultrasound showed new cycle pathways. NCS clinical manifestations are complicated, and need combination diagnosis of symptoms and auxiliary examination to determine surgical indications. Ligation of spermatic vein and vein anastomosis can be used to treat NCS.

Salvage Dual LDLT for HCC after Major Hepatectomy

Recurrence is the most frequent cause of treatment failure after hepatocellular carcinoma (HCC) resection. Salvage liver transplantation is a rescue treatment for recurrent HCC. However, salvage LT is considered about the technical feasibility in patients who have undergone prior liver surgery. Especially prior performance of a major liver resection, such as right lobectomy, makes subsequent recipient hepatectomy technically difficult. We report a successful case about salvage dual living donor liver transplantation(LDLT) after major hepatectomy. A 48-year-old male was transferred to our hospital because of gastrointestinal bleeding. He underwent the right hepatectomy due to hepatocelluar carcinoma four years ago. The gastroduodenoscopy and computed tomography demonstrated variceal beeding at duodenal 3rd portion. We performed transjugular intrahepatic portosystemic shunt(TIPS) and the coil embolization of collaterals. We recommended LDLT and because the right lobe volume of one donor, his wife was was not sufficient for the recipient and right to left lobe proportion of the other donor, his young sister is smaller than 30%, we performed dual LDLT from two donors who were his wife and young sister. At the operation, portal vein anastomosis of the right lobe graft was done using an interposing cadaveric iliac vein graft and the right gastroepiploic artery was anastomosed to the hepatic artery of the left lobe graft. Adequate portal venous and hepatic artery blood flow was demonstrated by intraoperative and postoperative Doppler ultrasound studies. Salvage dual LDLT could be undertaken successfully in adult patients with prior major hepatectomy under the accurate preoperative planning and proper surgical techniques.

Preliminary results of the first human uterus transplantation from a multiorgan donor

To describe the first-year results of the first human uterus transplantation case from a multiorgan donor. Case study. University hospital. A 21-year-old woman with complete müllerian agenesis who had been previously operated on for vaginal reconstruction. Uterus transplantation procedure consisting of orthotopic replacement and fixation of the retrieved uterus, revascularization, end to site anastomoses of bilateral hypogastric arteries and veins to bilateral external iliac arteries and veins was performed. Resumption of menstrual cycles. The patient had menarche 20 days after transplant surgery. She has had 12 menstrual cycles since the operation. We have described the longest-lived transplanted human uterus to date with acquirement of menstrual cycles.

Impact of localized ascites after pediatric living donor liver transplantation: report of three cases

Fluid collection is common after living donor liver transplantation (LDLT), and can include hematomas, bilomas, abscesses, and seromas. Although accumulated fluid rarely becomes infected and usually remains localized, localized ascites can sometimes be sufficiently extensive to induce vascular complications. This report presents three such cases in pediatric patients that underwent LDLT. A 33-month-old patient showed an increase in the volume of localized ascites around the hepatic vein anastomoses together with low hepatic vein flow on postoperative day (POD) 47. An 82-month-old patient showed an increase in the volume of localized ascites around the portal vein anastomoses together with low portal vein flow on POD 71. A 63-month-old patient showed an increase in the size of a localized abscess around the hepaticojejunostomy with dilatation of all of the intrahepatic bile ducts on POD 20. These cases illustrate the need for awareness of possible vascular or biliary complications due to compressive localized ascites after LDLT.

Successful Treatment of Refractory Ascites after Liver Transplantation with Splenic Artery Embolization

Introduction: Refractory ascites after orthotopic liver transplantation is rare. While secondary precipitating causes can be identified in a sizable number, a small proportion of the patients with post-transplantation ascites have no identifiable cause. Splenic artery embolization has recently been reported as an effective method of treating refractory ascites in such cases. We present a case of successful treatment of refractory ascites after liver transplantation with partial splenic artery embolization. Case: A 52-year-old Caucasian male had received an orthotopic liver transplant in March, 2011 for hepatocellular carcinoma and chronic hepatitis C induced liver cirrhosis. The patient developed refractory ascites 2 months after transplantation requiring repetitive therapeutic paracenteses. Liver biopsy and echocardiography showed no evidence of rejection or recurrent hepatitis and congestive heart failure, respectively. Transjugular hepatic venogram and pressure evaluation showed a kink at the anastomosis of right hepatic vein and inferior vena cava which was successfully stented with resolution of pressure gradient post intervention. The patient continued to have refractory ascites despite these measures and underwent partial splenic artery embolization (SAE) to decrease the inflow of blood to the portal circulation. After SAE, the patient had significant reduction in ascites with decreased need for paracentesis, improved renal function and reduced diuretic requirement. Discussion: Refractory ascites (RA) is an uncommon complication of orthotopic liver transplantation which poses a serious challenge to the clinician. It is associated with increased risk of renal failure and peritoneal infections, increased hospital stay and shortened survival. In majority of patients with RA, treatment of secondary causes including right sided heart failure, acute or chronic graft rejection and hepatic inflow or outflow obstruction, leads to resolution of ascites. In the patients with no identifiable cause, treatment of ascites is challenging. Transjugular intrahepatic portosystemic shunting has shown mixed results as a treatment strategy. Splenic artery embolization leading to decreased splenic inflow and decreased portal hypertension has shown encouraging results in the recent years. Conclusion: Owing to its effectiveness in decreasing portal hypertension and low complication risk, splenic artery embolization appears to an attractive treatment option for the challenging problem of refractory ascites after liver transplantation.

Hepatobiliary Quiz-3 (2012)

Hepatobiliary Quiz-3 (2012)

Hepatobiliary Quiz-3 (2012)

Hepatobiliary Quiz-3 (2012)

Nonsuture Anastomosis of Arteries and Veins Using the Magnetic Pinned-Ring Device: A Histologic and Scanning Electron Microscopic Study

The goal of this study was to evaluate the performance of the magnetic pinned-ring device for nonsuture vascular anastomosis. The magnetic pinned-ring device consists of paired magnetic rings that are coated with titanium nitride and embedded in a polypropylene shell; the rings are equipped with alternately spaced holes and titanium pins. The vascular anastomosis procedure using the novel magnetic pinned-ring device was performed on 14 mongrel dogs, and the traditional hand-sewing technique was used on 14 additional dogs. In situ end-to-end anastomoses were performed in the femoral artery and the inferior vena cava. Patency was confirmed through ultrasonographic scans at different time points as late as 24 weeks after surgery. Gross observation, histological staining, and scanning electron microscopy were used to evaluate the results at 24 weeks postoperatively. The time required to perform the vascular anastomosis was significantly shorter for the magnetic device than for hand sewing. A continuity of re-endothelialization was confirmed in all anastomotic stomas after 24 weeks, and neither formation of aneurysms nor thickening of the vascular wall was noted. The re-endothelialization was smooth at the anastomotic site of the magnetic device, whereas hand sewing resulted in rough and uneven re-endothelialization and the presence of visible sutures. Moreover, the endothelial cells were regularly arranged at the anastomotic site of the magnetic device, whereas different-sized and irregularly aligned endothelial cells were present at the hand-sewn anastomotic site. Use of the magnetic device was associated with significantly decreased deposition of fibrotic collagen and depressed infiltration of inflammatory cells compared with use of the hand-sewing technique. The magnetic pinned-ring device offers a simple, fast, reliable, and efficacious technique for nonsuture vascular anastomosis. Use of this device shortens operation time, maintains a high patency rate, and improves the healing of vascular tissue.

Sutura mecánica microvascular en cirugía reconstructiva de cabeza y cuello

ObjectivesTo evaluate the efficacy and applicability of mechanical microvascular anastomosis performed in the artery and vein in the studied series. Material and methodA retrospective study of 25 patients who underwent microsurgical reconstruction of head and neck. Data were collected by: graft type, coupler size, recipient vessels, intraoperative patency test, anastomosis time, need for revision of anastomosis, and graft failure (venous thrombosis or arterial failure). ResultsA series of 25 patients with 50 anastomosis. 25 venous, 22 arterial mechanical anastomisis and 3 converted to hand-sewn anastomosis. Recipient vessels: superior thyroid artery (70%) and venous branches of the thyro-linguo-facial common trunk (80%). The mean anastomosis time was 8min. Four patients required revision of the anastomosis, with a salvage rate of 25%. There were 3 failures, oneof which was a conversion to manual suturing. ConclusionMicrovascular mechanical anastomoisis is a technique with an efficiency at least equal to the hand-sewn artery and vein anastomosis, with a shorter anastomosis (60% time reduction) and arterial use with satisfactory results, taking into account certain restrictions.