Vein Interposition Graft Research Articles

Portal vein reconstruction using an autologous splenic vein graft at the superior mesenteric and portal vein confluence during pancreaticoduodenectomy

Introduction: Autologous vein graft reconstruction is needed in some cases following superior mesenteric portal vein (SMPV) resection during pancreatic cancer surgery. There have been no reports of reconstruction using a splenic vein autograft in a patient who underwent pancreaticoduodenectomy (PD). Methods: A 76-year-old woman was referred to our hospital for consultation based on a suspicion of pancreatic tumor. Computed tomography (CT) showed tumor in the uncinated process of the pancreas, approximately 40 x 30 mm in size, with narrowing of the superior mesenteric vein just below the SMPV confluence. Cytology of the pancreatic fluid revealed adenocarcinoma of the pancreas. She underwent PD and the mass was confirmed to have invaded the SMPV confluence. After clamping the splenic vein root with a vascular clamp, approximately 70 mm of the SMPV segment was resected. Then, the distal side of the pancreas with the splenic vein was raised and the splenic vein was dissected from the pancreas to harvest an autologous graft of the healthy splenic vein. Vascular reconstruction was performed using the 30-mm segment of the harvested splenic vein. The total time required for blocking and anastomosing the portal vein was 45 minutes. The final pathologic report revealed portal vein invasion, T4N0M0, and R0 resection. The patient received adjuvant chemotherapy. Follow-up CT at the 15th postoperative month showed a patent graft without evidence of recurrence. Conclusions: Splenic vein interposition grafting could be used in cases of PD with resection of the SMPV confluence, if the splenic vein is healthy.

Use of the superficial inferior epigastric vein as an unusual interpositional vein graft

Use of the superficial inferior epigastric vein as an unusual interpositional vein graft

125 Bladder Exstrophy Radial Artery Phalloplasty: Exstrophy Related Issues and Saphenous Vein Interposition Graft

125 Bladder Exstrophy Radial Artery Phalloplasty: Exstrophy Related Issues and Saphenous Vein Interposition Graft

Penetrating femoral artery injuries: an urban trauma centre experience.

This study reviews a single centre experience with penetrating femoral artery injuries. The records of all patients with femoral artery injuries admitted to the Trauma Centre at Groote Schuur Hospital from January 2002 to December 2012 were reviewed. These were analysed for demographics, injury mechanism, perioperative, and surgical management. Outcome was categorised by limb salvage. One-hundred and fifty-eight (158) patients with femoral artery injuries were identified. There were 144 (91%) men and 14 women with a mean age of 28years. Ninety-five percent (N = 150) sustained penetrating injuries. The superficial femoral artery (87%) was most commonly injured. The most common type of arterial injury was a laceration (39%) and transection (37%). Eighty-one (51%) patients had a primary repair, 53 (33%) patients had a vein interposition graft, and 16 patients (10%) had a prosthetic graft. There were 78 (51%) concomitant venous injuries, 11 were repaired, and 1 vein patch repair was performed (15.4%). There were 4 (2.5%) primary amputations and 10 (6.5%) secondary amputations. There were no deaths. Statistically significant risk factors for secondary amputation derived by univariate analysis were: ischaemia (p < 0.0001), neurological deficit due to ischemia (p < 0.001), temporary vascular shunting (p < 0.001), and the absence of a palpable pulse post-repair (p < 0.01). This study has a primary and secondary amputation rate of 2.5 and 6.5%, respectively. There was greater than 90% limb salvage rate. The outcome of threatened limbs due to femoral artery injury is good, provided that there is no delay to surgery.

Tissue Inhibitor of Metalloproteinase-3 (TIMP-3) induces FAS dependent apoptosis in human vascular smooth muscle cells.

Over expression of Tissue Inhibitor of Metalloproteinases-3 (TIMP-3) in vascular smooth muscle cells (VSMCs) induces apoptosis and reduces neointima formation occurring after saphenous vein interposition grafting or coronary stenting. In studies to address the mechanism of TIMP-3-driven apoptosis in human VSMCs we find that TIMP-3 increased activation of caspase-8 and apoptosis was inhibited by expression of Cytokine response modifier A (CrmA) and dominant negative FAS-Associated protein with Death Domain (FADD). TIMP-3 induced apoptosis did not cause mitochondrial depolarisation, increase activation of caspase-9 and was not inhibited by over-expression of B-cell Lymphoma 2 (Bcl2), indicating a mitochondrial independent/type-I death receptor pathway. TIMP-3 increased levels of the First Apoptosis Signal receptor (FAS) and depletion of FAS with shRNA showed TIMP-3-induced apoptosis was FAS dependent. TIMP-3 induced formation of the Death-Inducing Signalling Complex (DISC), as detected by immunoprecipitation and by immunofluorescence. Cellular-FADD-like IL-1 converting enzyme-Like Inhibitory Protein (c-FLIP) localised with FAS at the cell periphery in the absence of TIMP-3 and this localisation was lost on TIMP-3 expression with c-FLIP adopting a perinuclear localisation. Although TIMP-3 inhibited FAS shedding, this did not increase total surface levels of FAS but instead increased FAS levels within localised regions at the cell surface. A Disintegrin And Metalloproteinase 17 (ADAM17) is inhibited by TIMP-3 and depletion of ADAM17 with shRNA significantly decreased FAS shedding. However ADAM17 depletion did not induce apoptosis or replicate the effects of TIMP-3 by increasing localised clustering of cell surface FAS. ADAM17-depleted cells could activate caspase-3 when expressing levels of TIMP-3 that were otherwise sub-apoptotic, suggesting a partial role for ADAM17 mediated ectodomain shedding in TIMP-3 mediated apoptosis. We conclude that TIMP-3 induced apoptosis in VSMCs is highly dependent on FAS and is associated with changes in FAS and c-FLIP localisation, but is not solely dependent on shedding of the FAS ectodomain.

Abstract QS13: Bridging The Gap: Extending Free Flap Pedicle Length With Interposition Vein Grafts And Arteriovenous Loops

PURPOSE: The purpose of this study is to assess clinical outcomes for utilization of vein grafts and arteriovenous loops in the context of free flap reconstruction. Free tissue transfer in complex oncological and traumatic defects may require extension of the vascular pedicle to reach recipient vessels and complete microvascular anastomosis. This can be accomplished by using vein grafts as a bridging medium. When interposition vein grafts (IVG) are needed for extension of both the arterial and venous conduit, a temporary arteriovenous fistula (AV loop) can be constructed as an intermediary step. These techniques have traditionally been regarded with increased risk of thrombosis and flap failure, but the body of clinically relevant published data lags behind. METHODS: Following approval by our Institutional Review Board, we retrospectively analyzed patients requiring free flap reconstruction between March 2007 and June 2017. All patients utilizing any vein graft in this context were identified. Data collection included demographic, medical, surgical, and outcome variables. RESULTS: A total of 90 IVG were used in 56 patients, receiving a total of 54 free flaps. Reconstructive sites included: head/neck (29; 51.8%), breast (13; 23.2%), upper extremity/trunk (9; 16.1%), and lower extremity (5; 8.9%). Twenty out of 26 AV loops created received flaps (11 immediate; 9 staged). Five AV loops thrombosed in staging and were discarded; one patient died in staging due to medical comorbidity. The duration of staging ranged from 1 to 59 days (median=4). Forty-two procedures utilized IVG (n=22; 3 arterial conduit only, 13 venous conduit only and 6 both) or AV loops (n=19) in the index flap surgery, of which 10 (24.4%) were taken back for emergent flap salvage (2 AV loops, 8 IVG group). Seven of these cases (eight flaps) were successfully salvaged. In 13 cases (14 flaps) IVG was utilized for free flap salvage (3 arterial conduit IVG, 10 venous conduit IVG), with a 78.6% successful flap salvage rate (n=11). Out of 54 flaps overall, 11 flap failures occurred (20.4%; 95% CI 10.6–33.5%). All flap failures occurred in the patients that used any IVG (with or without AV loop) for immediate reconstruction (two in AV loop group, 1 in IVG for both conduits, 5 in IVG for single conduit) or failed salvage utilizing IVG (3 in IVG for single conduit). Of the nine staged AV loops that received flaps, flap survival was 100%. CONCLUSIONS: Interposition vein grafts and AV loops offer practical solutions for pedicle lengthening in order to successfully perform microvascular anastomosis, but increase risk of take-back and flap failure when utilized in the index flap surgery. Our data demonstrate that staged AV loops may be superior to immediate AV loops, owing to a de facto pre-identification of patients who may otherwise develop a flap complication after immediate reconstruction. Additionally, IVG appears to be an especially effective tool in cases of free flap salvage. T.J. Bos: None. N.A. Calotta: None. M.Y. Seu: None. B.H. Cho: None. A.H. Hassanein: None. G.D. Rosson: None. D.S. Cooney: None. J.M. Sacks: None.

V09-01 BLADDER EXSTROPHY RADIAL ARTERY PHALLOPLASTY: EXSTROPHY RELATED ISSUES AND SAPHENOUS VEIN INTERPOSITION GRAFT

You have accessJournal of UrologyPediatric Urology1 Apr 2018V09-01 BLADDER EXSTROPHY RADIAL ARTERY PHALLOPLASTY: EXSTROPHY RELATED ISSUES AND SAPHENOUS VEIN INTERPOSITION GRAFT Giovanni Chiriaco, Gideon Blecher, Mark Johnson, Philippa Sangster, Nim Christopher, and David Ralph Giovanni ChiriacoGiovanni Chiriaco More articles by this author , Gideon BlecherGideon Blecher More articles by this author , Mark JohnsonMark Johnson More articles by this author , Philippa SangsterPhilippa Sangster More articles by this author , Nim ChristopherNim Christopher More articles by this author , and David RalphDavid Ralph More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2173AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Bladder exstrophy is a congenital abnormality that occurs along a spectrum of the exstrophy-epispadias complex. Cases of penile reconstruction are often difficult in men with bladder exstrophy due to prior and potential future surgeries and abnormal anatomy. Interposition grafts may be used in cases where vessels cannot be anastomosed directly. METHODS This video shows the surgical steps of complex penile reconstruction and discusses specific exstrophy related issues. A 37 year old man with micropenis secondary to bladder exstrophy previously underwent numerous reconstructive procedures including failed mitrofanoff channel. He had multiple abdominal scars and a stretched penile length of 5cm. His condition was impairing his psychological heath and sexual relationships. Full thickness buttock skin grafts are harvested. The radial artery forearm flap is dissected and cephalic vein, radial artery and cutaneous sensory nerves are isolated. The micropenis is disassembled, the glans divided and the corpora cavernosa amputated. For arterial supply usual end-to-side radial artery to common femoral anastomosis is not possible, due to pelvic distraction and vessels being further away from the phallus. Multiple prior and potential surgeries (for example Mitrofanoff revision) could risk the inferior epigastric artery injury with potential abdominal skin or neophallus devascularisation. Thus interposition graft is required – at the groin, the long saphenous vein has issues with tortuosity, valves and higher risk of thrombosis and bleeding. The ankle segment is better suited as it is straight, smaller and will appropriately limit inflow thus reducing bleeding. With an operative microscope, the radial artery is anastomosed to the distal end of the saphenous vein graft, the cephalic vein to the great saphenous vein and an end-to-side anastomosis is next performed between the interposition graft and the common femoral artery. The ilio-inguinal nerve is then sutured to the sensory phallus nerves. The previously harvested skin grafts are applied to the forearm. A Doppler ultrasound is used to confirm the arterial flow. RESULTS The post operative time has been uneventful and a saphenous vein interposition graft was successfully used. CONCLUSIONS Typically, a tension free anastomosis is created from the inferior epigastric artery to the radial artery phalloplasty. We demonstrate the use of a saphenous vein interposition graft between the radial artery and the common femoral artery for the creation of a tension free anastomosis. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e903 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Giovanni Chiriaco More articles by this author Gideon Blecher More articles by this author Mark Johnson More articles by this author Philippa Sangster More articles by this author Nim Christopher More articles by this author David Ralph More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V79 - Bladder exstrophy radial artery phalloplasty: Exstrophy related issues and saphenous vein interposition graft

V79 - Bladder exstrophy radial artery phalloplasty: Exstrophy related issues and saphenous vein interposition graft

Early animal model evaluation of an implantable contrast agent to enhance magnetic resonance imaging of arterial bypass vein grafts.

Background Non-invasive monitoring of autologous vein graft (VG) bypass grafts is largely limited to detecting late luminal narrowing. Although magnetic resonance imaging (MRI) delineates vein graft intima, media, and adventitia, which may detect early failure, the scan time required to achieve sufficient resolution is at present impractical. Purpose To study VG visualization enhancement invivo and delineate whether a covalently attached MRI contrast agent would enable quicker longitudinal imaging of the VG wall. Material and Methods Sixteen 12-week-old male C57BL/6J mice underwent carotid interposition vein grafting. The inferior vena cava of nine donor mice was treated with a gadolinium-diethylenetriaminepentaacetic acid (Gd-DTPA)-based contrast agent, with control VGs labeled with a vehicle. T1-weighted (T1W) MRI was performed serially at postoperative weeks 1, 4, 12, and 20. A portion of animals was sacrificed for histopathology following each imaging time point. Results MRI signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were significantly higher for treated VGs in the first three time points (1.73 × higher SNR, P = 0.0006, and 5.83 × higher CNR at the first time point, P = 0.0006). However, MRI signal enhancement decreased consistently in the study period, to 1.29 × higher SNR and 2.64 × higher CNR, by the final time point. There were no apparent differences in graft morphometric analyses in Masson's trichrome-stained sections. Conclusion A MRI contrast agent that binds covalently to the VG wall provides significant increase in T1W MRI signal with no observed adverse effects in a mouse model. Further optimization of the contrast agent to enhance its durability is required.

Vascular Injury and Its Management: Experience at Universal College of Medical Sciences, Bhairahawa, Nepal

INTRODUCTION: Vascular trauma is a common life-threatening injury leading to serious consequences if not timely and efficiently managed. Although they represent less than 3% of all injuries, they deserve special attention because of their severe complications. The aim of this study was to analyze the causes of injury, presentations, surgical (recent) approaches, outcomes, and complications of vascular trauma. MATERIALS &amp; METHODS: This was a retrospective analysis performed over 6 months. From December 2015 to May 2016, 12 patients were included in the study and were operated upon for peripheral vascular injuries. Diagnosis was made by physical examination as well as with hand Doppler alone or in combination with Doppler scan. Primary vascular repair was carried out whenever possible; however, if it was not possible, an interposition vein graft was placed. RESULTS: Of the total 12 patients who sustained major vascular injuries during this period, 9 sustained injuries to the upper limb vessels, 3 had injuries of the lower limb vessels. Trauma with sharp object was the cause in 4 cases, blunt trauma was the cause in 4 cases and rupture pesudoaneurysm was the cause in 2 cases and ruptured aneurysm was the cause in 2 cases. Of the 12 patients, 12 patients were successfully managed by vascular reconstruction without any residual disability. There were 8 male patients (66.67%) and 4 female patients (33.33%), and their ages ranged from 16–60 years (mean 35 years). CONCLUSION: Patients who suffer vascular injuries should be transferred to vascular surgery centers as soon as possible. Decisive management of peripheral vascular trauma will maximize patient survival and limb salvage. Priorities must be established in the management of associated injuries, and delay must be avoided when ischemic changes are present.Journal of Universal College of Medical Sciences (2017) Vol.05 No.01 Issue 15, Page: 8-11

Treatment Strategies and Outcomes of Infections After Carotid Interventions

Infections after carotid endarterectomy are a devastating but rare complication, with paucity of literature providing guidelines for management of this complex issue. In this study, we report the experience of a single institution's management of carotid infections occurring after carotid interventions. A retrospective chart review was performed to document presentation, treatment, and outcomes of patients who underwent surgical intervention for carotid infections from 2002 to 2017. Primary end points were mortality and stroke. Secondary end points were cranial nerve injuries, reinfections, and reinterventions. Twenty-nine patients with mean age of 69 ± 2 years (76% male) were treated for carotid infections. Index operation was performed elsewhere in 27 (93%) patients, and 7 (24%) of these patients had prior secondary reinterventions (4 had carotid stenting and 3 had surgical revisions). The most common symptom on presentation was abscess or purulent drainage in 19 (66%) patients; 7 (24%) patients presented with active bleeding, and 10 (34%) patients had carotid pseudoaneurysms. Computed tomography was the diagnostic imaging of choice in 27 of 29 (93%) patients. Incision and drainage were performed in seven patients (five of these were done elsewhere before transfer). Wound and blood cultures were positive in 16 and 2 patients, respectively; the most common organisms identified were staphylococcus and streptococcus (83%). A combination of prosthetic (n = 15) and bovine (n = 5) patches was used at index operation. Median time to presentation was 7 months (range, 0.3-194 months). Femoral vein graft interposition was used for carotid replacement in 24 patients (83%), femoral vein patch angioplasty in 1 (3%), and saphenous vein patch angioplasty in 4 (14%). Early complications included stroke in one patient (3%) and death in one patient on postoperative day 11 from multiorgan system failure (3%). Three patients had tracheostomy (one for prolonged ventilator dependence, one had bilaterally paretic vocal cords, and one had a history of radiation therapy for laryngeal cancer). Cranial nerve injury occurred in eight patients (28%); all resolved at last follow-up. Mean length of hospital stay was 10 ± 1 days. Carotid occlusion occurred in one patient (3%) at 3 months with no clinical sequelae. Follow-up duplex ultrasound did not show any evidence of graft stenosis. At mean follow-up of 17 ± 4 months, there were no carotid reinfections or reinterventions. Treatment of carotid infections with replacement using femoral vein can be performed safely with a low risk of stroke and mortality. This repair is durable at midterm follow-up without clinical complications of reinfection or reintervention.

A Lifeboat in Stormy Seas: A Vein Graft of Last Resort

Case Presentation: A 57 year old male underwent salvage surgery for recurrent left maxillary sarcoma: orbital exenteration and extensive tissue resection, including loss of the original flap. The defect was reconstructed with a large right osteocutaneous scapula flap, which failed at postoperative day 4 due to sepsis. At postoperative day 14, the patient underwent tertiary reconstruction with a fasciocutaneous anterolateral thigh flap. The internal and external jugular veins were found to be unsuitable recipient vessels, so an interpositional vein graft (IVG) was planned. The left cephalic, then right saphenous veins were exposed in turn: both were unsuitable because of previous vascular access procedures. The right superficial inferior epigastric vein (SIEV) was harvested, providing 14 centimetres of vessel for use as an IVG. The flap was successful, and the patient was discharged 14 days later.

Early Outcomes of Vein Grafting for Reconstruction of Brachial Arterial Injuries in Children.

We postulated that, with microsurgical technique, vascular reconstruction with interpositional vein grafts in the pediatric population is safe and results in sustained vascular patency and excellent midterm outcomes. Twenty children with brachial artery injuries were treated with interpositional vein grafting at a tertiary pediatric hospital from 1995 to 2013. Medical records were evaluated for demographic, clinical, and radiographic data. Ten patients were available for longer-term follow-up. Pain at rest, pain with exercise, and temperature intolerance were assessed with visual analog scale (VAS) (range, 0-5). Functional outcomes were assessed using the Pediatric Outcomes Data Collection Instrument (PODCI) and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires. Graft patency and flow were characterized via duplex sonography. Peak flow velocity and resistive index (RI) were compared with the contralateral extremity. Median patient age at the time of injury was 7.75 years (range, 4.6-11.5 years) and median follow-up was 1.75 years (range, 0.3-6.3 years). All patients had perfused hands with palpable radial pulses at follow-up. There were no clinically meaningful differences in motion, sensibility, or strength between affected and unaffected limbs. Mean VAS scores for pain at rest, pain with exercise, and temperature intolerance were 0.4, 0.4, and 0.6, respectively. Mean global PODCI and DASH scores were 98.0 and 5.1, respectively. Nine of 10 patients had patent arteries with normal flow patterns. In the patient with graft occlusion, there was collateralization around the elbow with normal reconstitution of the distal vessels. Mean peak flow velocity proximal and distal to the graft were 77.7 cm/s and 66.5 cm/s, respectively. Mean RI of the graft were 0.84 and 0.77, respectively. Brachial artery reconstruction using interpositional vein graft and microsurgical technique is safe and effective and results in excellent functional outcomes in children. Therapeutic V.

Surgical Treatment of Cervical Carotid Artery Aneurysm

Cervical carotid aneurysms are rare, and surgical treatment should be planned for each patient. The authors report 9 cases of cervical carotid aneurysm in 9 patients(mean age, 53.7 years;5 men)who were treated surgically between 2005 and 2014. The aneurysm was located in the internal carotid artery in 6 patients, the common carotid artery in 2 patients, and the carotid bifurcation in 1 patient. Four aneurysms were recurrences after a previous endovascular intervention(parent artery coil embolization, covered stent placement, or stent with coil embolization). The mean interval between the endovascular therapy and the onset of the present illness was 6 years. All the patients presented a mass effect at the neck, including lower cranial nerve dysfunction in 1 patient. Two patients presented with ischemic events presumably due to thromboembolism from the target aneurysms. Surgical treatments included local vascular reconstruction procedures in 6 patients(interposition vein or artificial graft bypass in 5 patients and in situ bypass in 1 patient). Four aneurysms were then resected. Two patients with rich collateral blood flow were treated with ligation of the parent artery proximal to the aneurysm. Surgical complications included embolic stroke and cranial nerve dysfunction in 2 patients, respectively, both presumably due to surgical manipulation. The modified Rankin scale(mRS)score at discharge was 0 in 5 patients, 1 in 1 patient, 2 in 2 patients, and 6 in 1 patient(vascular tumor). Surgical treatment of cervical carotid aneurysms seems a reasonable treatment of choice, but lower nerve dysfunction and embolism from the aneurysm should be avoided.

Interpositional Lateral Thoracic Vein Graft for DIEP Flap Salvage in Setting of Superficial Venous System Dominance.

Interpositional Lateral Thoracic Vein Graft for DIEP Flap Salvage in Setting of Superficial Venous System Dominance.

Hepatic arterial reconstruction using saphenous vein graft interposition for distal pancreatectomy with celiac axis resection

Objective: We report two cases required hepatic arterial reconstruction during distal pancreatectomy with celiac axis resection (DP-CAR). Methods: Case 1, 54 years old male patent underwent DP-CAR for his pancreas cancer. As radical antegrade modular pancreatosplenectomy (RAMPS) approach, Common hepatic artery was resected first then isolation of inferior pancreatoduodenal artery (IPDA) from supra mesenteric artery (SMA) was attempted. However IPDA was injured then hepatic arterial flow was lost. Total pancreatectomy and subtotal gastrectomy was performed to avoid pancreatic fistula and ischemia of the stomach. Then hepatic arterial reconstruction using saphenous vein graft interposition between infra-renal abdominal aorta and proper hepatic artery was performed. Case 2, 75 years old male patient underwent DP-CAR using RAMPS for his pancreas cancer. After lost hepatic arterial flow due to IPDA injury, saphenous vein graft was immediately harvested to minimize ischemia time. DP-CAR was performed and the stomach was preserved, then arterial reconstruction was performed as same as case 1. Results: Case 1, Hemorrhage from stomach stump was remarkable in his postoperative course. The patient is having malnutrition but not suffered from recurrence for 7 months after the surgery. Case 2, The patient developed delayed postoperative pancreatic fistula and bleeding from SMA. The patient died at postoperative day 82. Conclusion: RAMPS for DP-CAR may have a pit fall to keep hepatic arterial flow safe. The hepatic artery reconstruction using saphenous vein graft was feasible in our series. However reconstruction of the gastric arterial flow and minimize ischemia time should be considered for longterm prognosis.

Medial sural artery as a salvage recipient vessel for complex post traumatic microvascular lower limb reconstruction.

Complex lower extremity trauma still poses a formidable challenge for micro vascular reconstruction. The extensive surrounding zone of trauma can make it difficult to find a suitable recipient pedicle for anastomosis. A need was felt for exploration of newer recipient vessels in lower extremity which could be harnessed for reliable and tension free micro anastomosis. The purpose of the present report is to highlight the possibility of using medial sural artery for safe micro vascular anastomosis in selected scenarios like vessel depleted extremity. Between 2008 and 2013, we used the medial sural vessels for micro anastomosis in 10 cases of lower extremity trauma. All the cases had severe soft tissue trauma with or without a bony defect. A computed tomography angiogram (CTA) of the involved extremity revealed either severe perivascular scarring around the standard recipient vessels or patency of just a single vessel. However, in all cases a patent medial sural pedicle was identified on CTA. Interposition vein grafts (IVGs) were used in most cases to ensure a tension free anastomosis. In all cases, unscarred medial sural vessels were identified with average dissected length and diameter being 6.2 cm (range 4 to 7.5 cm) and 2 mm (range 1.5 to 2.5 mm) respectively. Vein graft [average length 5.6 cm (range 4 to 15 cm)] was interposed in seven cases, while in remaining three, long saphenous vein was used for vein anastomosis. All the flaps survived after the surgery. There was one re-exploration for evacuation of peri-anastomotic hematoma with no adverse effect on flap survival. The mean follow up period was 27.6 months. In the four cases with bone reconstruction, bony union was seen between 5 and 8 months. They were able to walk without aids and resume work after 10-14 months, following a structured rehabilitation program. The patients with soft tissue reconstruction (6 cases) could carry out aid free locomotion and resume their routine after 4-6 weeks. There were no long term complications in any of the flap. Medial sural artery may prove to be a reliable recipient pedicle for use in complex lower extremity trauma cases and could possibly provide a safer alternative in cases with severe perivascular scarring or in a "single vessel" extremity.

Potential Implication of Interpositional Vein Graft and Postoperative Heparinization for Successful Finger Replantation

Potential Implication of Interpositional Vein Graft and Postoperative Heparinization for Successful Finger Replantation

Pellet Embolization after Subclavian Artery Injury: A Case Report

Acute upper limb ischemia caused by a gunshot penetrating vascular injury and subsequent arterial embolization by foreign body is uncommon in everyday practice and is associated with high morbidity/mortality rates, especially with emergency surgery. We present the case of a 72-year old male who attempted suicide using a gun. A gunshot entry wound was evident in the right upper chest region with no pellet exit wound. Radial pulses were palpable bilaterally. Angiography revealed right subclavian artery direct injury and pellet embolization to the brachial artery. The patient underwent open surgery, with reversed saphenous vein interposition graft to replace subclavian artery defect. A pellet was removed by a separate arteriotomy in the brachial artery. Associated injuries were clavicle-comminuted fracture and subclavian vein injury. The patient remained well 5 months later with no reported complications. In conclusions, the presence of radial pulses alone on clinical exam cannot rule out the presence of a significant vascular injury.

Antimicrobial-bonded graft patency in the setting of a polymicrobial infection in swine (Sus scrofa)

BackgroundPolytetrafluoroethylene (PTFE) and Dacron are commonly used as arterial conduits in vascular trauma or infection when vein interposition graft may not be available. This study used a previously validated large animal model of polymicrobial infection to assess the patency and infectious resistance of a novel, antibiotic-impregnated graft material compared with PTFE and Dacron. MethodsForty-eight animals were placed into five groups for a 21-day survival period. A 6-mm PTFE, Dacron, or antimicrobial-bonded graft was used to replace the iliac artery and then inoculated with 1 × 107 colonies/mL of genetically labeled Pseudomonas aeruginosa and Staphylococcus aureus. Native vessels with and without contamination served as control groups. The primary end points were graft patency (determined by duplex ultrasound and necropsy) and graft infection (culture with molecular analysis). Secondary end points included physiologic measurements, blood cultures, laboratory data, and histopathology. ResultsAt 21 days, 50% of PTFE, 62.5% of Dacron, and 100% of the antimicrobial-bonded grafts remained patent (P = .04). PTFE and Dacron had an equivalent number of overall infections, 87.5% and 75%, respectively (P = 1.0). There was no significant difference of infectious organisms between standard materials. The infection rate of the antimicrobial-bonded graft (25%) was significantly less than that of both PTFE and Dacron (P < .01), and all of these infections were secondary to P. aeruginosa. Clinical data did not vary significantly between groups. There were no mortalities in the protocol secondary to graft blowout or sepsis. ConclusionsThe antimicrobial-bonded graft material outperformed standard PTFE and Dacron in the setting of polymicrobial infection with regard to graft patency and infection. The novel prosthetic material appears to be resistant to infection with S. aureus and to limit the growth of P. aeruginosa. Additional studies are recommended to explore the role of this antibiotic-bonded graft for use in the setting of vascular infection or trauma.