Preservation Of Vessels Research Articles

Laparoscopic Spleen-Preserving Distal Pancreatectomy

To compare preservation with the division of the splenic vessels in the surgical management of laparoscopic spleen-preserving distal pancreatectomy. Bicentric retrospective study. Prospectively maintained databases. Between January 1997 and January 2011, 140 patients who underwent laparoscopic spleen-preserving distal pancreatectomy for benign or lowgrade malignant tumors in the body/tail of the pancreas were included. Patients treated with the attempted splenic vessel preservation were compared with patients treated with the attempted division of the splenic vessels (Warshaw technique). Operative outcomes and postoperative morbidity were evaluated. The outcomes of 55 patients in the splenic vessel preservation group were compared with those of 85 patients in the Warshaw technique group. The clinical characteristics were similar in both groups, except for tumor size, which was significantly greater in the Warshaw technique group (33.6 vs. 42.5 mm; P=.001). The mean operative time, mean blood loss, and rate of conversion to the open procedure did not differ between the 2 groups. The rate of successful spleen preservation was significantly improved following the splenic vessel preservation technique (96.4% vs. 84.7%; P=.03). Complications related to the spleen only occurred in the Warshaw technique group (0% vs. 10.5%; P=.03), requiring a splenectomy in 4 patients (4.7%). The mean length of stay was shorter in the splenic vessel preservation group (8.2 vs. 10.5 days; P=.01). The short-term benefits associated with the preservation of the splenic vessels should lead to an increased preference for this technique in selected patients undergoing laparoscopic spleen-preserving distal pancreatectomy for benign or low-grade malignant tumors in the body/tail of the pancreas.

異なる血管アプローチを要した膵インスリノーマに対する腹腔鏡下脾温存膵体尾部切除術の2例

異なる血管アプローチを要した膵インスリノーマに対する腹腔鏡下脾温存膵体尾部切除術の2例

Outcome of Loupe-Assisted Sub-inguinal Varicocelectomy in Infertile Men

Dear Editor, In report on varicocele and infertility (1, 2), varicocele treatment should be offered to the male partner of a couple attempting to conceive, when all of the following are present: 1) a varicocele is palpable; 2) the couple has documented infertility; 3) the female has normal fertility or potentially correctable infertility; and 4) the male partner has one or more abnormal semen parameters or sperm function test results. If a varicocele is palpable in physical examination, color doppler may not be necessary. Most experts perform inguinal or subinguinal microscopic varicocelectomy. Techniques using optical magnification maximize preservation of arterial and lymphatic vessels while reducing the risk of persistence or recurrence of varicocele (3). Varicocelectomy is associated a small risk of wound infection, hydrocele, persistence or recurrence of varicocele and, rarely, testicular atrophy. Microscopic varicocelectomy successfully eliminates over 90% of varicocele. Most studies have reported that semen quality improves in a majority of patients following varicocele repair. Surgical correction of varicocele results in significant improvement in semen parameters in up to two thirds of afflicted men, and 30% to 60% of the couples will achieve pregnancy as a result of varicocelectomy. If clinical center had not microscopic instrument, Loupe assisted varicocelectomy might be useful.

Laparoscopic extended (subtotal) distal pancreatectomy with resection of both splenic artery and vein

Spleen-preserving distal pancreatectomy can be performed safely and effectively by resecting both splenic vessels (Warshaw procedure). This simplified spleen-preserving technique might also be applied to minimally invasive distal pancreatectomy of benign and borderline malignant tumor. Although the conservation of both splenic vessels is paramount to preserving the spleen during laparoscopic distal pancreatectomy, preservation of the splenic vessels is not always possible, especially under the following conditions: (1) relatively large tumor, (2) associated with chronic pancreatitis, (3) tumor abutting splenic vascular structures, and (4) bleeding during the splenic vessel conserving procedure, which are potential indications of laparoscopic extended Warshaw procedure. Patient preparation and position was the same as that described in our previous study. During the study's time period, 38 consecutive patients underwent laparoscopic spleen-preserving distal pancreatectomy. Of those, five patients underwent a laparoscopic extended Warshaw procedure, which all included among 16 patients of extended distal pancreatectomy by dividing the pancreas at the pancreatic neck. All patients were women with a median age of 55 (range, 38-75) years. Median total operation time and blood loss were 215 (range, 200-386) minutes and 100 (range, 0-300) ml, respectively. The median length of hospital stay was 8 (range, 5-15) days. All of postoperative complications (two grade A and two grade B postoperative pancreatic fistula; one grade A bleeding) were able to be treated conservatively. During the median follow-up period of 11 (range, 7-42) months, one focal splenic infarction and one gastric varix were noted; however, no clinically significant complications were reported. Laparoscopic spleen-preserving extended distal pancreatectomy with resection of both the splenic vessels is feasible and safe. This surgical technique is thought to increase the chance of preservation of the spleen with minimally invasive distal pancreatectomy in well-selected benign or borderline malignant tumor of the distal pancreas.

Laparoscopic Distal Pancreatectomy with Preservation of the Spleen and of the Splenic Vessels, with Autologous Islet Transplantation. a New Minimally Invasive Technique to Treat Benign Neoplasm of the Pancreatic Body. Case Series of 3 Patients

Introduction: Benign pancreatic neoplasm located in the left pancreas can require resection because of the risk of malignant transformation. Distal pancreatectomy for body-neck lesions frequently results in postoperative diabetes because of the great amount of normal resected pancreatic tissue. Autologous islet transplantation (AIT) can prevent this event. The association of AIT, laparoscopic technique and the preservation of the spleen can minimize all the possible consequences of surgery in such cases. We herein present a case series of 3 non diabetic patients who underwent spleen preserving left laparoscopic pancreatectomy for symptomatic cystic lesions. Materials and methods: Three non-diabetic, female patients (age 37-44) were candidate to surgery because of pancreatic cystic lesions between May and September 2011. The lesions were located at the body/neck of the pancreas and measured 3, 4 and 10cm respectively. The planned operation was a laparoscopic spleen-preserving left pancreatectomy with preservation of the splenic vessels, associated with AIT from the normal pancreas distal to the neoplasm. Results: The procedure was successfully performed in all the three cases. Mean operation time was 266 minutes. Surgical complications occurred in one patient (grade A pancreatic fistula). Postoperative stay was 6, 6, and 7. Histopathological evaluation revealed mucinous cystic neoplasm in 2 cases e serous cystic neoplasm in 1 case. Pancreas weight was 33, 22, 30g and 105.200, 40.390, 94.790 Islet equivalents were isolated respectively and infused in the portal vein by percutaneous transhepatic approach the day after surgery. No early postoperative insulin administration was needed. One patient developed a transient partial portal thrombosis 2 months after islet infusion. The 3 patients are insulin independent at a mean follow up of 7 months. Conclusions: The combination of minimally invasive approach and autologous islets transplantation is safe and effective in prevent post surgical diabetes after resection for benign neoplasm located in the body-neck of the pancreas.

In Situ Fenestration for Branch Vessel Preservation during EVAR

In Situ Fenestration for Branch Vessel Preservation during EVAR

In Situ Fenestration For Branch Vessel Preservation During Evar

The Methodist DeBakey Cardiovascular Journal provides timely updates on important topics in cardiovascular medicine with quarterly, thematic review-article issues. Each issue is curated by subject-matter-expert guest editors and includes invited reviews along with case reports, interesting multimodality images, and humanities submissions. Additional case reports, images, CME quizzes, and editorials are published on a continuous basis online. MDCVJ is geared towards cardiologists, cardiovascular surgeons, general practitioners, and CV residents and fellows and is indexed in PubMed and MEDLINE.MDCVJ is published by Houston Methodist DeBakey Heart & Vascular Center as part of DeBakey CV Education, an epicenter for cardiovascular academic and clinical education programs located in the heart of the Texas Medical Center. Along with the Journal, DeBakey CV Education offers online and hands-on training for cardiovascular healthcare professionals at all stages in their careers. DeBakey CV Education’s vast YouTube library features hundreds of training videos and live webcasts, including Journal features. Subscribe to the YouTube channel today and sign up for newsletter updates about training opportunities.

A Strong Regenerative Ability of Cardiac Stem Cells Derived From Neonatal Hearts

Human cardiac stem cells (CSCs) promote myocardial regeneration in adult ischemic myocardium. The regenerative capacity of CSCs in very young patients with nonischemic congenital heart defects has not been explored. We hypothesized that isolated neonatal-derived CSCs may have a higher regenerative ability than adult-derived CSCs and might address the structural deficiencies of congenital heart disease. Human specimens were obtained during routine cardiac surgical procedures from right atrial appendage tissue discarded from 2 age groups: neonates and adults patients. We developed a reproducible isolation method that generated cardiosphere-derived cells (CDCs), regardless of starting tissue weight or age. Neonatal-derived CDCs demonstrated increased number of cardiac progenitor cells expressing c-kit(+), flk-1, and Islet-1 by flow cytometry and immunofluorescence. When transplanted into infarcted myocardium, neonatal-derived CDCs had a significantly higher ability to preserve myocardial function, prevent adverse remodeling, and enhance blood vessel preservation and/or formation when compared with adult-derived CDCs. Last, neonatal-derived CDCs were more cardiomyogenic than adult-derived CDCs when cocultured with neonatal cardiomyocytes and displayed enhanced angiogenic function compared with adult-derived CDCs. Neonatal-derived CDCs have a strong regenerative ability when compared with adult-derived CDCs that may depend on angiogenic cytokines and an increase prevalence of stem cells. This has important implications in the potential use of CDCs in future clinical trials.

E-014 Endovascular occlusion of trigeminal artery-cavernous fistula following spontaneous rupture of a persistent trigeminal artery (PTA): technical considerations and case report

PurposeTo report a rare case of spontaneous rupture of dysplastic trigeminal artery in the cavernous sinus, imaging findings and technical considerations for treatment with vessel preservation.Case reportA 47-years-old female presented...

O-033 A historical perspective on the treatment of carotid cavernous fistulas: The 16-year barrow neurological institute experience

Introduction/PurposeA carotid cavernous fistula (CCF) is a spontaneous or acquired connection between the carotid artery and cavernous sinus. These lesions classically present with chemosis, exopthalmos, and ocular bruit secondary to...

Reconstructive endovascular treatment of a ruptured vertebral artery dissecting aneurysm using the Pipeline embolization device

BackgroundThe Pipeline embolization device has been used successfully to treat intracranial aneurysms with difficult morphologies. However, the need for dual antiplatelet therapy has limited its use after subarachnoid hemorrhage.Case reportA...

Molded Parallel Endografts for Branch Vessel Preservation during Endovascular Aneurysm Repair in Challenging Anatomy

Parallel endografts (also known as snorkels or chimneys) are a proposed strategy for increasing the applicability of endovascular repair to aneurysms involving branch vessels. One major disadvantage of this strategy is the imperfect nature of seal inherent to having multiple side-by-side endografts. In this article, the use of odd-shaped parallel endografts to facilitate apposition and improve seal is proposed and a technique to mold a round stent graft into an "eye" shape using balloons is described.

Pulsed Laser-Induced Liquid Jet for Skull Base Tumor Removal with Vascular Preservation through the Transsphenoidal Approach

Background: The transsphenoidal approach has recently been used to treat complex lesions beyond the sella turcica, but the difficulties of dealing with small vessels may limit the procedure. To overcome these problems, we have developed a pulsed laser-induced liquid jet (LILJ) system to dissect tumor tissue with preservation of fine blood vessels, and evaluated its utility and safety.

A Scoring System (DISTAL) for Predicting Failure of Snuffbox Arteriovenous Fistulas

ObjectivesA first fistula failing will lead to serious morbidity in a proportion of patients. Snuffbox fistulas have the advantage of proximal vessel preservation, and although several factors have been associated with failure, the relative importance of these factors combined and their clinical applicability is unknown. The aim of this study was to determine the relative importance of risk factors for snuffbox fistula failure and create a simple scoring system to aid fistula placement decision making. Methods218 consecutive patients were examined using Cox regression analysis to determine risk factors for failure. Primary patency was used as the endpoint. ResultsDiabetes, IHD, Stroke, Two snuffbox procedures, Age > 70 and Less than 2.0 mm vein (DISTAL, maximum score 6) were significant predictors of primary patency failure. There was a clear decrease in primary patency with increasing DISTAL score (log rank χ2 = 30.3, DF = 5, P < 0.001). Performing snuffbox procedures on patients with a score ≤3 would give a 23% reduction in the number of failures within two months for a 12% reduction in the number of patients offered snuffbox procedures. ConclusionThe DISTAL scoring system could give large improvements in primary patency for the snuffbox fistula if the results can be validated in other datasets.

A single-centre experience and follow-up of patients with endovascular coiling of large and giant intracranial aneurysms with parent artery preservation

Large and giant aneurysms are some of the most challenging vascular pathologies in the central nervous system. Their peculiarities make the surgical and endovascular approaches difficult and frequently limit them by posing risks and complications. Endovascular coil embolization of these lesions is being used increasingly as an alternative. Here we report the clinical experience and follow-up results of the endosaccular packing of 102 consecutive patients with 106 large or giant aneurysms to assess the efficacy and safety of this method. Embolization was completed by packing the aneurysm sac with a variety of commercially available coils. Primary endosaccular coiling, balloon-assisted coiling and stent-assisted coiling were used. The technical feasibility of the procedure, procedure-related complications, angiographic results, clinical outcome and follow-up angiography were evaluated. During admission, immediate angiography demonstrated complete occlusion in 48.1%, neck remnant in 28.3%, and incomplete occlusion in 23.6%. Procedure-related morbidity and mortality was 7.5% and 2.8%, respectively. A favorable clinical outcome (Modified Rankin Scale score of 0–2) was observed in 88.2% of patients (average follow-up time, 56.5months). No re-hemorrhage of a treated aneurysm occurred. Angiography follow-up was obtained in 77.5% (79/102) patients (average follow-up time, 38.1months). The overall recanalization rate was 29.6%. Comparison of occlusion class immediately after treatment and at last follow-up showed that 80.2% of the 81 aneurysms (in 79 patients) were stable or had improved. Five stent-assisted aneurysms that were not completely occluded initially had converted to complete occlusion on last follow-up. Nineteen recanalized aneurysms underwent successful re-embolization. No procedural complication was seen at retreatment. We conclude that in treating large and giant intracranial aneurysms, endovascular coiling with parent vessel preservation is a safe and effective technique.

Pararenal aortic aneurysm repair using fenestrated endografts

We performed a systematic review of the current literature to analyze the immediate and follow-up results of fenestrated endovascular aortic aneurysm repair (F-EVAR) in patients with pararenal abdominal aortic aneurysms (AAAs). The Medline, Embase, and Cochrane databases were searched to identify all studies reporting F-EVAR of pararenal AAAs published between January 2000 and May 2011. Two independent observers selected studies for inclusion, assessed the quality of the included studies, and performed the data extraction. Studies were selected based on specific predefined criteria. Outcomes were technical success (successfully completed procedure with endograft patency, preservation of target vessels, and no evidence of type I or III endoleak at postprocedural imaging), 30-day mortality, all-cause mortality, branch vessel patency, renal impairment, and secondary interventions. Between-study heterogeneity was calculated using I(2) statistics. Pooled estimates were calculated using a fixed-effects (I(2) <25%) or a random-effects (I(2) >25% to <50%) model. Nine studies were included reporting 629 patients who underwent F-EVAR for a pararenal AAA, of which 1622 target vessels were incorporated in an endograft design. Between-study heterogeneity was ≤ 41% for all outcomes. The pooled estimate (95% confidence interval [CI] was 90.4% (87.7%-92.5%) for technical success, 2.1% (1.2%-3.7%) for 30-day mortality, and 16% (12.5%-20.4%) for all-cause mortality. Follow-up was 15 to 25 months. The pooled estimate (95% CI) during follow-up was 93.2% (90.4%-95.3%) for branch vessel patency, 22.2% (16%-30.1%) for renal impairment, and 17.8% (13.5%-22.6%) for secondary interventions. Promising immediate and midterm results (up to 2 years) support F-EVAR as a feasible, safe, and effective treatment in a relatively high-risk cohort of patients with pararenal AAAs.

Vessel health and preservation (Part 1): a new evidence-based approach to vascular access selection and management.

Vascular access for the infusion of medications and solutions requires timely assessment, planning, insertion, and assessment. Traditional vascular access is reactive, painful, and ineffective, often resulting in the exhaustion of peripheral veins prior to consideration of other access options. Evidence suggests clinical pathways improve outcomes by reducing variations and establishing processes to assess and coordinate care, minimizing fragmentation and cost. Implementation of a vascular access clinical pathway leads to the intentional selection of the best vascular access device for the patient specific to the individual diagnosis, treatment plan, current medical condition, and the patient's vessel health (1). The Vessel Health and Preservation (VHP) programme incorporates evidence-based practices focused on timely, intentional proactive device selection implemented within 24 hours of admission into any acute facility. VHP is an all-inclusive clinical pathway, guiding clinicians from device selection through patient discharge, including daily assessment. Initiation of the VHP programme within a facility provides a systematic pathway to improve vascular access selection and patient care, allowing for the reduction of variations and roadblocks in care while increasing positive patient outcomes and satisfaction. Patient safety and preservation of vessel health is the ultimate goal.

Laparoscopic assisted sigmoid resection for diverticular disease

Laparoscopic assisted sigmoid resection (LASR) has become a widely accepted procedure in colorectal surgery. In the last decade, numerous variations of surgical details have been established. In order to demonstrate a feasible technique, this video is provided. LASR is performed using four ports. The first port is inserted via open access by a minilaparotomy in the right paraumbilical region. Two ports are sited in the right lower abdomen, including one 12-mm port in the following incision above the pubic symphysis. The forth port is inserted in the left upper abdomen. The procedure starts with the removal of adhesions, the peritoneal incision is performed medially, and a medial to lateral approach to the mesocolon and the inferior mesenteric artery (IMA) is carried out. After identifying the left ureter, the IMA is either clipped or sealed about 1.5 to 2 cm from the origin in order to preserve the autonomous plexus. Then dissection is continued on Gerota's fascia. After lifting the rectosigmoid, dissection is continued in the avascular plane until the mesentery of the upper rectum is mobilized. Then the remaining lateral adhesions are dissected with preservation of the gonadal vessels and the left ureter. The distal resection line is always in the upper rectum, which is easily identified by the lack of tenia. After sealing the mesorectum, the rectum is dissected using a linear stapler. Thereafter, a minilaparotomy above the pubic symphysis is performed and a device for protection and retraction of the wound is inserted. Dissection of the mesosigmoid and the descending colon is carried out extracorporally. The anvil of a circular stapling device is inserted in the descending colon, which is then returned into the peritoneal cavity. Running sutures closes the incision, and the anastomosis is carried out laparoscopically in a "double stapling" technique. The video describes the efficacy and technical feasibility of laparoscopic surgery for diverticular disease and demonstrates its effect regarding perioperative morbidity and functional outcome.

Use of covered chimney stents for pararenal aortic pathologies is safe and feasible with excellent patency and low incidence of endoleaks

To present the clinical experience of consecutive series with use of balloon-expandable and self-expanding chimney endografts (balloon-expandable covered stent group [BECS] vs self-expanding covered stent group [SECS]) in the endovascular treatment of challenging aortic pathologies requiring renal and/or visceral revascularization. Between January 2009 and May 2011, data for 37 high-risk patients from one center and 35 patients from another institution, with pararenal aortic pathologies treated by the chimney endovascular technique, were prospectively collected. The chimney-graft technique is based on the deployment of a covered or bare-metal stent parallel to the aortic endograft, thereby creating a conduit that runs outside the aortic main endograft, and has been proposed to ensure secure proximal fixation extending the sealing zones. Forty-six consecutive target vessels (43 renal arteries and 3 superior mesenteric arteries) were revascularized by the Advanta (Atrium, Hudson, NH) BECS (1.2 chimneys/patient); in contrast, 81 consecutive target vessels (64 renal arteries, 11 superior mesenteric arteries, and 6 celiac trunks) were revascularized by the Viabahn (Gore, Flagstaff, Ariz) SECS (2.3 chimneys/patient). The success rate for target vessel preservation was 97.8% for the BECS group and 100% for the SECS group in the entire follow up. There was one symptomatic left renal artery occlusion of the BECS group treated by open thrombectomy of the left renal artery and placement of 8-mm Dacron (BBraun, Aesculap AG, Tuttlingen, Germany) iliorenal bypass. Additionally, one patient underwent repeat balloon angioplasty with a 5-mm balloon due to high-grade in-stent stenosis of a 6 × 59 Advanta stent graft 12 months postoperatively. Overall, one perioperative (and not present in the computed tomography angiography at discharge) type Ia endoleak was detected in the BECS group. In contrast, five perioperative type Ia endoleaks were present in the SECS group; however, only one of them was persistent in the radiological imaging and was treated by proximal extension of a 5-mm cuff, 1 year postoperatively, due to continuous aneurismal sac increase. No patient of any subgroup developed postoperative persistent renal insufficiency with need of hemodialysis. Thirty-day and during the follow-up procedure-related mortality was 0% for both BECS and SECS groups. In summary, midterm results of use of covered chimney stents for pararenal aortic pathologies show safety and feasibility with excellent patency and low incidence of endoleaks.

Alternate indications for varicocele repair: non-obstructive azoospermia, pain, androgen deficiency and progressive testicular dysfunction

Varicocele repair is indicated for infertile men with clinical varicoceles. Some men with scrotal pain, low testosterone, non-obstructive azoospermia, and who are at risk for testicular dysfunction may also benefit from varicocelectomy.