Comparing Clinical and Aesthetic Outcomes of Digital Artery Flap Using Nail Bed Graft for Fingertip Amputation with Replantation

BACKGROUND

Digital artery flap (DAF) with nail bed graft is a simple method to preserve finger length for fingertip amputations. This study compared the clinical and aesthetic outcomes between replantation and DAF.

METHODS

Patients who underwent replantation or DAF for a single fingertip amputation (Ishikawa subzone II or III) at the authors' hospital from 2013 to 2021 were retrospectively evaluated. The aesthetic and functional outcomes were finger length and nail deformity at the final follow-up, total active motion, grip strength, Semmes-Weinstein monofilament test, Fingertip Injuries Outcome Score, and Hand20 score.

RESULTS

Overall, in 74 analyzed cases (40 replantation, 34 DAF), the median operative time and the median length of hospital stay were longer with replantation than with DAF (188 versus 126 minutes; P < 0.01; 15 versus 4 days; P < 0.01). The success rates of replantation and DAF were 82.5% and 94.1%, respectively. The rate of finger shortening with replantation was significantly lower than with DAF (42.5% versus 82.4%; P < 0.01). There were fewer nail deformities with replantation than with DAF (45.0% versus 67.6%; P = 0.06). The proportion of patients who achieved excellent or good Fingertip Injuries Outcome Score and median Hand20 score were not significantly different between the groups (89.5% versus 85.3%, P = 0.61; 8.0 versus 13.5, P = 0.42, respectively). Median postoperative Semmes-Weinstein monofilament test values were similar between the groups (3.61 versus 3.61; P = 0.23).

CONCLUSION

In this retrospective study, compared with replantation, DAF for fingertip amputations achieved equivalent postoperative functional outcomes and shorter intraoperative time and hospital stays, but resulted in inferior cosmetic outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Modeling human anti-pig xenoimmune responses in a pig artery tissue grafted humanized mouse model

BACKGROUND

Blood vessels that contain endothelial cells (ECs) on the surface are in direct contact with host blood and are the first target of xenograft rejection. Currently, our understanding of human anti-pig vessel immune responses is primarily based on in vitro assays using pig ECs. Therefore, it is necessary to develop an animal model that permits in vivo study of human immunological rejection of pig vessels.

METHODS

Pig artery tissues (PAT) were transplanted into human immune system (HIS) mice or immunodeficient NSG mice (as controls). Intragraft human immune cell infiltration and antibody deposition were quantified using histology and immunohistochemistry. Donor antigen-specific immune responses were quantified using a mixed lymphocyte reaction and a complement-dependent killing assay.

RESULTS

Pig CD31+ ECs were detected and increased 2-fold from weeks 3 to 5 in PAT xenografts from immunodeficient NSG mice. However, compared with NSG mice, PAT xenografts in HIS mice had significantly lower numbers of porcine CD31+ ECs and showed a marked reduction from week 3 to week 5. PAT xenograft rejection in HIS mice is associated with intensive infiltration of human immune cells, deposition of human IgM and IgG antibodies, and the formation of a tertiary lymphoid structure. Robust donor pig antigen-specific human T cells and antibody responses were detected in PAT-transplanted HIS mice.

CONCLUSION

We have developed a humanized mouse model to evaluate human anti-pig xenoimmune responses by PAT transplantation in vivo. This model is expected to facilitate the refinement of pig gene-editing strategies (the expression on EC surface) and the testing of local immunosuppressive strategies for clinical pig organ xenotransplantation.

Cryopreservation moderates the thrombogenicity of arterial allografts during storage

INTRODUCTION

Management of vascular infections represents a major challenge in vascular surgery. The use of cryopreserved vascular allografts could be a feasible therapeutic option, but the optimal conditions for their production and use are not precisely defined.

AIMS

To evaluate the effects of cryopreservation and the duration of storage on the thrombogenicity of femoral artery allografts.

METHODS

In our prospective study, eleven multi-organ-donation-harvested human femoral arteries were examined at five time points during storage at -80°C: before cryopreservation as a fresh native sample and immediately, one, twelve and twenty-four weeks after the cryopreservation. Cross-sections of allografts were perfused with heparin-anticoagulated blood at shear-rates relevant to medium-sized arteries. The deposited platelets and fibrin were immunostained. The thrombogenicity of the intima, media and adventitia layers of the artery grafts was assessed quantitatively from the relative area covered by fibrin- and platelet-related fluorescent signal in the confocal micrographs.

RESULTS

Regression analysis of the fibrin and platelet coverage in the course of the 24-week storage excluded the possibility for increase in the graft thrombogenicity in the course of time and supported the hypothesis for a descending trend in fibrin generation and platelet deposition on the arterial wall. The fibrin deposition in the cryopreserved samples did not exceed the level detected in any of the three layers of the native graft. However, an early (up to week 12) shift above the native sample level was observed in the platelet adhesion to the media.

CONCLUSIONS

The hemostatic potential of cryopreserved arterial allografts was retained, whereas their thrombogenic potential declined during the 6-month storage. The only transient prothrombotic change was observed in the media layer, where the platelet deposition exceeded that of the fresh native grafts in the initial twelve weeks after cryopreservation, suggesting a potential clinical benefit from antiplatelet therapy in this time-window.

Influence of the new standardized clinical cryopreservation/slow thawing protocol on immunogenicity of arterial allografts in rats

Objectives and design

At the present time there are two waiting list for patients with vascular prosthetic infection indicated for arterial transplantation in the Czech Republic. The inclusion of each patient for cold-stored or cryopreserved arterial transplantation is the preference of indicating surgeon. In this experimental work we studied the immunogenicity of rat aortal allografts treated by our new clinical cryopreservation/slow thawing protocol.

Material and methods

Brown-Norway (BN) (N = 6, 203–217 g) or Lewis (LEW) (N = 6, 248–254 g) abdominal aortal grafts treated in accordance with our new clinical cryopreservation/slow thawing protocol were orthotopically transplanted to Lewis recipients (N = 12, 191–245 g). Aortal wall histology and infiltration by recipient immune cells, as well as donor specific anti MHC class I and II antibodies in recipient serum were studied in both isografts and allografts on day 30 postransplant. Core data of cryopreserved allografts were compared to our previous data of cold-stored aortal allografts treated in accordance with our clinical cold-storage protocol.

Results

Cryopreserved allografts showed regular morphology of aortal wall with clear differentiation of all three basic anatomical layers on day 30 postransplant. Intimal layer showed no hyperplasia, luminal surface was covered by endothelial cells. No statistical difference was observed in tunica media thickness between isografts and allografts. The medial layer showed no necrosis, shrinkage or immunoglobuline G deposition in any experimental group. The adventitial infiltration by immune cells was significantly higher (P<0.05) in allografts. Cryopreserved allografts showed significant lower activation of both cell- and antibody mediated immunity compared to historical data of cold-stored allografts.

Conclusion

Aortal wall histology of rat allografts treated by our new standardized clinical cryopreservation/slow thawing protocol was comparable to that of the cryopreserved isografts on day 30 posttranspant. The immunogenicity of cryopreserved aortal allografts was significantly lower compared to that of cold-stored aortal allografts.

Successful management of the supraclavicular artery island flap combined with a sternohyoid muscle flap for hypopharyngeal and laryngeal reconstruction

This retrospective study evaluated operative outcomes when using a supraclavicular artery island flap (SAIF) combined with a sternohyoid muscle flap (SHMF) to reconstruct defects after hypopharyngeal carcinoma resection. Reconstructive surgery for hypopharyngeal and laryngeal defects was performed with the SAIF + SHME combination in 6 patients during 2016 to 2018. Within 14 to 16 days after the surgery, all 6 patients could ingest food and block the tube (avoiding aspiration), with no pharyngeal fistulas. They then underwent irradiation up to a total of 60.5 Gy during the 4 weeks postoperatively. All 6 flaps survived, and there were no donor-site complications except minor dehiscence in 1 patient. Thus, the SAIF + SHMF combination can be used to reconstruct hypopharyngeal and laryngeal defects after hemi-laryngectomy in patients with hypopharyngeal carcinoma involving the unilateral larynx. This technique effectively preserved the swallowing function and phonation of the patients, thereby improving their quality of life.

Ten Year Experience of Using Cryopreserved Arterial Allografts for Distal Bypass in Critical Limb Ischaemia

OBJECTIVE/BACKGROUND

In critical limb ischaemia (CLI), current guidelines recommend revascularisation whenever possible, preferentially through endovascular means. However, in the case of long occlusions or failed endovascular attempts, distal bypasses still have a place. Single segment great saphenous vein (GSV), which provides the best conduit, is often not available and currently there is no consensus about the best alternative graft.

METHODS

From January 2006 to December 2015, 42 cryopreserved arterial allografts were used for a distal bypass. Autologous GSVs or alternative autologous conduits were unavailable for all patients. The patients were observed for survival, limb salvage, and allograft patency. The results were analysed with Kaplan-Meier graphs.

RESULTS

Estimates of secondary patency at one, two and five years were 81%, 73%, and 57%, respectively. Estimates of primary patency rates at one, two and five years were 60%, 56%, and 26%, respectively. Estimates of limb salvage rates at one, two and five years were 89%, 89%, and 82%, respectively. Estimates of survival rates at one, two and five years were 92%, 76% and 34%, respectively. At 30 days, major amputations and major adverse cardiac events were one and zero, respectively. Six major amputations occurred during the long-term follow up.

CONCLUSION

Despite a low primary patency rate at two years, the secondary patency of arterial allografts is acceptable for distal bypasses. This suggests that cryopreserved arterial allografts are a suitable alternative for limb saving distal bypasses in the absence of venous conduits, improving limb salvage rates and, possibly, quality of life.

A Flow Dynamic Rationale for Accelerated Vascularized Composite Allotransplant Rejection

BACKGROUND

From 1996 to 2000, Diefenbeck et al. carried out six knee vascularized composite allotransplants. The allotransplants were composed of bone, soft tissue, and femoral vascular pedicle (25 to 40 cm). All rejected between 14 and 56 months. Failures were attributed to chronic rejection. In 2008, the Louisville team lost their fourth patient's hand transplant at 8 months. During the rejection workup, intraoperative findings noted a thickened arterial pedicle attributed to intimal hyperplasia with significant fibrotic perivascular tissue and a near "no-flow phenomenon." No cutaneous rejection was appreciated and failure was attributed to chronic rejection.

METHODS

Data were collected from two teams, one in Germany and the other in Louisville, Kentucky. The population under study consisted of the six knee and one hand transplants. The factor of interest was the long donor arterial pedicle. The outcome measurements were transplant survival time and histopathologic results.

RESULTS

There are only seven published vascularized composite allotransplant cases where a donor artery longer than 25 cm was used. This cohort represents a 100 percent accelerated failure rate. The cause of these losses remains unexplained. The donor arteries suffered from T-cell-mediated rejection and ischemia-induced media/adventitial necrosis.

CONCLUSIONS

We hypothesize that the donor artery rejected at an accelerated rate because of ischemia caused by disruption of the external vasa vasorum in conjunction with intimal hyperplasia induced by T-cell-mediated rejection that led to disruption of the Windkessel effect. Loss of this effect presented as intimal hyperplasia accelerated by ischemia causing an expedited transplant failure.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Comparison of venous repair results using either arterial or vein grafts in a crush-avulsion injury model

Background/aim

Venous insufficiency after replantation or revascularization is one of the most common causes of limb loss in either the short or the long term. The aim of this study was to evaluate the results of a new technique to overcome venous insufficiency.

Materials and Methods

A crush-avulsion type of injury was formed in the femoral veins of rats of 3 separate groups. In the control group, primary repair was applied to the damaged veins and the remaining 2 groups were repaired with either an arterial graft or a vein graft. The success rates of anastomosis were then compared.

Results

In the control group the patency rate was 25% in the 2nd hour, 12.5% on the 2nd day, and 12.5% on the 10th day. The patency rate in the vein group was 87.5% in the 2nd hour, 50% on the 2nd day, and 37.5% on the 10th day, whereas the patency rates in the artery group were 100% in the 2nd hour, 87.5% on the 2nd day, and 75% on the 10th day.

Conclusion

Microsurgery requires experience and patience. It can be considered that the use of arterial grafts for venous repair in replantation after crush-avulsion type amputations can increase the success rate of replantation.

[Decellularized cadaveric human artery for substitution of connective tissue and smooth muscle defects on the example of tunica albuginea of penis (experimental work)]

AIM

To analyze experimentally the outcomes of xenotransplantation (cadaveric artery, decellularized cadaveric artery) for tunica albuginea defects repair.

MATERIAL AND METHODS

The study included 60 chinchilla rabbits. Rabbits underwent local replacement of tunica albuginea. Animals were divided into 2 groups (group 1 - human cadaveric artery, group 2 - decellularized cadaveric artery). The result was considered after 7, 14 and 30 days postoperatively.

RESULTS

Tendency to stasis, sludge-phenomenon and ultimately development of fibrosis of transplantation area were histologically observed in group 1 after 30 days. In group 2 luminal surface of decellularized artery was smoothed, fibrin and blood elements were absent. In group 1 mean level of C-reactive protein was 3.86±0.43, 1.17±0.2 and 0.73±0.16 mg/L after 7, 14 and 30 days respectively. In group 2 the same values were 0.33±0.03, 0.23±0.03 and 0.11±0.02 mg/L. Differences were significant (t =-46.28, t = -25.95, t = -14.84; p<0.0001).

B cell phenotypes in baboons with pig artery patch grafts receiving conventional immunosuppressive therapy

BACKGROUND

In the pig-to-baboon artery patch model with no immunosuppressive therapy, a graft from an α1,3-galactosyltransferase gene-knockout (GTKO) pig elicits a significant anti-nonGal IgG response, indicating sensitization to the graft. A costimulation blockade-based regimen, e.g., anti-CD154mAb or anti-CD40mAb, prevents sensitization. However, neither of these agents is currently FDA-approved. The aim of the present study was to determine the efficacy of FDA-approved agents on the T and B cell responses.

METHODS

Artery patch xenotransplantation in baboons was carried out using GTKO/CD46 pigs with (n = 2) or without (n = 1) the mutant transgene for CIITA-knockdown. Immunosuppressive therapy consisted of induction with ATG and anti-CD20mAb, and maintenance with different combinations of CTLA4-Ig, tacrolimus, and rapamycin. In addition, all 3 baboons received daily corticosteroids, the IL-6R blocker, tocilizumab, at regular intervals, and the TNF-α blocker, etanercept, for the first 2 weeks. Recipient blood was monitored for anti-nonGal antibody levels by flow cytometry (using GTKO/CD46 pig aortic endothelial cells), and mixed lymphocyte reaction (MLR). CD22+B cell profiles (naïve [IgD+/CD27-], non-switched memory [IgD+/CD27+], and switched memory [IgD-/CD27+] B cell subsets) were measured by flow cytometry. At 6 months, the baboons were euthanized and the grafts were examined histologically.

RESULTS

No elicited anti-pig antibodies developed in any baboon. The frequency of naïve memory B cells increased significantly (from 34% to 90%, p = 0.0015), but there was a significant decrease in switched memory B cells (from 17% to 0.5%, p = 0.015). MLR showed no increase in the proliferative T cell response in those baboons that had received CTLA4-Ig (n = 2). Histological examination showed few or no features of rejection in any graft.

CONCLUSIONS

The data suggest that immunosuppressive therapy with only FDA-approved agents may be adequate to prevent an adaptive immune response to a genetically-engineered pig graft, particularly if CTLA4-Ig is included in the regimen, in part because the development of donor-specific memory B cells is inhibited.

[Role of the homograft bypass in extremity inferior's reconstructions]

INTRODUCTION

Vascular homografts are used for limb salvage in cases of graft infection after previous reconstructive vascular surgery or inadequate autologous veins. During multi-organ donation the thoracic aorta segment, aortic bifurcation, iliac arteries, femoral arteries, popliteal arteries, femoral veins and greater saphenous veins can be harvested. Our aim was to optimize the use of homografts by analyzing the results of previous procedures.

METHODS

The patient information was processed retrospectively, using the clinical computer system. 162 procedures were performed on 144 patients between 2007 and 2014. The short- and long-term patency, hemorrhagic complication rate, amputation rate and mortality was examined in our study. The location, graft type and length of cryopreservation were taken into consideration. Aortoiliac and femoropopliteal reconstructions with arterial and venous homografts were examined.

RESULTS

The mean age of the patients was 63.6 ± 10.7 years, the mean follow-up period was 36 ± 28 months. The primary patency rates at the postoperative 1, 3 and 6 months were 83.7%, 75.0% and 63.4%. In this study the arterial and deep venous homografts had better primary patency rates compared to the superficial venous homografts: at the postoperative 1, 3, 6 months the arterial homograft results were 85.6%, 78.6% and 74.3%, the greater saphenous vein homograft results were 81.4%, 70.4% and 47.7% in the same intervals.

CONCLUSION

The reconstructive surgical procedures in septic area mean serious challenge for the vascular surgeons. The AB0 compatibility of the graft and the recipient did not result better long-term outcomes compared to the non-compatible grafts. According to our data the ideal choice of homogenous graft is an arterial homograft which was not cryopreserved longer than 6 months.

Posterior Thigh Flap Pedicled on the Cutaneous Vessels Arising From the Popliteo-posterior Intermediate Artery: A Report of 5 Cases

Surgical repair of soft tissue defects of the knee and leg remains challenging. Using a case study approach, the anatomy of the popliteo-posterior intermediate cutaneous artery was examined, and a reverse island flap method was developed and implemented. After obtaining informed consent, 5 patients (1 woman, 4 men, age range 31 to 57 years) underwent the experimental use of a reverse island flap with a posterior thigh flap pedicled on the cutaneous vessels arising from the popliteo-posterior intermediate artery to repair soft-tissue defects of the knee and leg. The defects were caused by burned skin below the knee (n = 1), progressive skin necrosis in the knee after fracture surgery (n = 2), and skin infections associated with diabetes mellitus (n = 2). Skin defect sizes ranged from 15 cm x 5 cm to 30 cm x 12 cm. These large defects did not heal spontaneously; wound duration ranged from 1 week to 1 year, and all patients had refused defect repair with free flaps. Patients received posterior thigh flaps pedicled on the popliteo-posterior intermediate artery with areas ranging from 17 cm x 6 cm to 25 cm x 12 cm. All patients were treated with antibiotics and local dressings (iodoform and alcohol) changed daily post surgery, and blood supply was monitored by assessing the texture and color of the flap and venous regurgitation (ie, vein drainage disturbance). Four (4) of the five flaps survived completely. In 1 patient, partial survival of the flap, which had a good blood supply despite a venous circulation disorder, occurred: in this case, complete survival was achieved after treatment with a retrograde fascial flap and skin grafting. The appearance and texture of all flaps were satisfactory (ie, patients underwent only 1 operation, healing time was approximately 2 weeks, flap quality was close to normal skin, the donor site closed directly, and the shape and function of the knee and leg recovered well). No donor site abnormality was observed, and no postsurgical infection occurred. More research is needed, but the use of a reverse island flap with a posterior thigh flap pedicled on the cutaneous vessels arising from the popliteo-posterior intermediate artery may be a feasible option to repair soft tissue defects of the knee and leg.

Clinical Outcomes of Cryopreserved Arterial Allograft Used as a Vascular Conduit for Hemodialysis

This single center cohort study aimed to test the hypothesis that use of a cryopreserved arterial allograft could avoid the maturation or healing process of a new vascular access and to evaluate the patency of this technique compared with that of vascular access using a prosthetic graft. Between April 2012 and March 2013, 20 patients underwent an upper arm vascular access using a cryopreserved arterial allograft for failed or failing vascular accesses and 53 using a prosthetic graft were included in this study. The mean duration of catheter dependence, calculated as the time interval from upper arm access placement to removal of the tunneled central catheter after successful cannulation of the access, was significantly longer for accesses using a prosthetic graft than a cryopreserved arterial allograft (34.4 ± 11.39 days vs. 4.9 ± 8.5 days, P < 0.001). In the allograft group, use of vascular access started within 7 days in 16 patients (80%), as soon as from the day of surgery in 10 patients. Primary (unassisted; P = 0.314) and cumulative (assisted; P = 0.673) access survivals were similar in the two groups. There were no postoperative complications related to the use of a cryopreserved iliac arterial allograft except for one patient who experienced wound hematoma. In conclusion, upper arm vascular access using a cryopreserved arterial allograft may permit immediate hemodialysis without the maturation or healing process, resulting in access survival comparable to that of an access using a prosthetic graft.

Endovascular Treatment of Aneurysmal Deterioration in Peripheral Arterial Allografts

Purpose:

To report endovascular treatment of 2 patients with aneurysmal deterioration of peripheral arterial allografts.

Case Report:

Two men (65 and 64 years old) who had undergone an arterial allograft reconstruction for infection of prosthetic infrapopliteal bypass grafts 5 and 7 years ago, respectively, were diagnosed with asymptomatic aneurysmal deterioration of the allografts. Stent-graft repair was successful in both cases, completely excluding the aneurysms. At ≥1 year, continued aneurysm exclusion was confirmed by duplex scan, with no evidence of endoleak, migration, or stenosis.

Conclusion:

Endovascular treatment may be a useful therapeutic option when treating patients with late peripheral allograft deterioration.

Initial in vivo experience of pig artery patch transplantation in baboons using mutant MHC (CIITA-DN) pigs

BACKGROUND

In the pig-to-nonimmunosuppressed baboon artery patch model, a graft from an α1,3-galactosyltransferase gene-knockout pig transgenic for human CD46 (GTKO/CD46) induces a significant adaptive immune response (elicited anti-pig antibody response, increase in T cell proliferation on MLR, cellular infiltration of the graft), which is effectively prevented by anti-CD154mAb-based therapy.

METHODS

As anti-CD154mAb is currently not clinically applicable, we evaluated whether it could be replaced by CD28/B7 pathway blockade or by blockade of both pathways (using belatacept + anti-CD40mAb [2C10R4]). We further investigated whether a patch from a GTKO/CD46 pig with a mutant human MHC class II transactivator (CIITA-DN) gene would allow reduction in the immunosuppressive therapy administered.

RESULTS

When grafts from GTKO/CD46 pigs were transplanted with blockade of both pathways, a minimal or insignificant adaptive response was documented. When a GTKO/CD46/CIITA-DN graft was transplanted, but no immunosuppressive therapy was administered, a marked adaptive response was documented. In the presence of CD28/B7 pathway blockade (abatacept or belatacept), there was a weak adaptive response that was diminished when compared with that to a GTKO/CD46 graft. Blockade of both pathways prevented an adaptive response.

CONCLUSION

Although expression of the mutant MHC CIITA-DN gene was associated with a reduced adaptive immune response when immunosuppressive therapy was inadequate, when blockade of both the CD40/CD154 and CD28/B7 pathways was present, the response even to a GTKO/CD46 graft was suppressed. This was confirmed after GTKO/CD46 heart transplantation in baboons.

Comparison of different autogenous graft materials for reconstruction of large segment vas deferens defect: experimental study in rat

PURPOSE

Vasectomy is one of the most common urological operations performed, and provides permanent contraception. Many vasectomized men ultimately seek vasectomy reversal because of unforeseen changes in lifestyle. Vasovasostomy has varying rates of success. In this study, we utilize vas deferens (VD), artery, and vein grafts to reconstruct 30% and 50%defects of the total vas deferens length.

MATERIALS AND METHODS

Forty two male Wistar rats were divided into three groups as VD graft, carotid artery and external jugular vein transplantations. Each group was equally divided into 2 different subgroups according to the length of transplant material as 1.0 cm (n = 7) and 1.5 cm (n = 7). To evaluate whether these materials may be used for long segment vas deferens reconstruction, the patency rate, partial or total graft occlusion, and histologic examination of all specimens were examined.

RESULTS

No patency was found in any of the grafts and many of them suffered destructive changes in anatomic structure. Sperm granulomas were determined around the testicular side anastomosis due to accumulated semen fluid which was in our belief, a result of aperistaltic zone caused by the grafts.

CONCLUSION

When the poor results obtained in our study are put into perspective, vasoepididymostomy is the only treatment method to date for reconstruction of large segment vas deferens defects.

Composite arterial grafting

The success of coronary artery bypass grafting, the gold standard for the treatment of multivessel coronary artery disease, is limited by poor long-term vein-graft patency. By contrast, the left internal mammary artery has been demonstrated to have a superior graft patency rate and has provided excellent clinical results. This suggests that the use of arterial conduits for coronary artery bypass grafting may be beneficial for long-term results. Recently, there has been an upsurge in the use of arterial grafts for myocardial revascularization based on the clinical advantage of the use of the left internal mammary artery as a bypass conduit. Many retrospective studies have supported the safety and the effectiveness of arterial grafting, and it has become apparent that the free arterial graft can be used as a branched or a lengthened conduit to the in situ arterial graft by adopting one or more of the several composite grafting techniques. Arterial composite grafts with or without sequential grafting techniques appear an attractive strategy as increased number of distal coronary anastomoses can be performed, with a limited number of grafts, avoiding proximal aortic anastomoses. However, concerns regarding the total dependence of the coronary bypass flow on the flow of one in situ arterial graft and technical error, resulting in compromised flow in one or both limbs of the composite graft have prevented composite arterial grafting from being universally adopted. It is expected that in the near future a prospective, multi-institutional, randomized controlled trial, to compare the short- and long-term outcomes of exclusive arterial grafting using composite and conventional aortocoronary revascularization strategies, will be undertaken to validate the safety and efficacy of composite arterial grafting.

[Repair of degloving injury of fingertip with vascular pedicled cross finger flap]

OBJECTIVE

To investigate the effectiveness of cross finger flap pedicled with the dorsal branch of proper digital artery in repairing degloving injury of the fingertip.

METHODS

Between January 2010 and June 2012, 13 cases of degloving injury of single fingertip were treated, including 9 males and 4 females with an average age of 33.6 years (range, 17-46 years). The defect locations were index finger in 5 cases, middle finger in 3 cases, ring finger in 3 cases, and little finger in 2 cases, including 4 cases of mechanical injury, 6 cases of twist injury, and 3 cases of crushing injury. The extent of skin avulsion was beyond the distal interphalangeal joint. The length of the avulsion was 1.0-2.1 cm (mean, 1.8 cm). Complicated injuries included phalangeal fracture in 2 cases. The time from injury to operation was 90-330 minutes (mean, 150 minutes). The wound was repaired with the cross finger flap pedicled with the dorsal branch of proper digital artery. The size of flaps ranged from 3.2 cm x 2.3 cm to 4.2 cm x 3.1 cm. After 3-4 weeks, the pedicle was cut. The donors were closed by skin graft.

RESULTS

Tension blisters of the flap and partial necrosis of skin graft occurred in 3 cases and in 1 case respectively, which were cured after symptomatic treatment; the flap and skin graft survived, and primary healing was obtained in the other cases. Thirteen patients were followed up 6-10 months (mean, 7 months). The texture and appearance of all the flaps were satisfactory. At 6 months after operation, two-point discrimination ranged from 7 to 10 mm (mean, 8.1 mm). The total active movement of the fingers were excellent in 10 cases and good in 3 cases, and the excellent and good rate was 100%.

CONCLUSION

The treatment of degloving injury of fingertip with the cross finger flap pedicled with the dorsal branch of proper digital artery is recommendable for the advantages of reliable blood supply, simple operation, high survival rate of the flap, good function recovery of the finger, and satisfactory appearance.

[Modified sural neurocutaneous vascular flap based on single dominant perforator arising from peroneal artery for coverage of defects over Achilles tendon]

OBJECTIVE

To report the operative techniques and clinical results of specially designed sural neurocutaneous vascular flap pedicled on a dominant perforator (the diameter > or = 0.8 mm) of the peroneal artery for coverage of soft tissue defects overlying the Achilles tendon.

METHODS

An approximately rectangular sural neurocutaneous vascular flap pedicled on the lowest dominant perforator arising from the peroneal artery was designed and harvested to repair defects over the Achilles tendon. The pedicle was located at a certain part of the flap, which divided the flap into the distal and the proximal parts. After the tendon was repaired, the flap was rotated 180 degrees based on the perforator and the position of the distal and proximal parts of the flap was changed to cover the defects and part of the donor site respectively. In most cases, skin graft was not needed.

RESULTS

The modified flaps were applied in 15 cases. All flaps (ranged from 13 cm x 15 cm - 18 cm x 9 cm ) were transplanted successfully without necrosis, and no vascular problems occurred. Following up for 10-17 months showed both satisfactory functional and cosmetic results.

CONCLUSIONS

The modified flap has reliable blood supply and the special design provides nearly normal outline of the ankle which favorites shoe wearing. It' s an excellent option for covering defects overlying the Achilles tendon.

Reperfusion injury intensifies the adaptive human T cell alloresponse in a human-mouse chimeric artery model

OBJECTIVE

Perioperative nonimmune injuries to an allograft can decrease graft survival. We have developed a model for studying this process using human materials.

METHODS AND RESULTS

Human artery segments were transplanted as infrarenal aortic interposition grafts into an immunodeficient mouse host, allowed to "heal in" for 30 days, and then retransplanted into a second mouse host. To induce a reperfusion injury, the healed-in artery segments were incubated for 3 hours under hypoxic conditions ex vivo before retransplantation. To induce immunologic rejection, the animals receiving the retransplanted artery segment were adoptively transferred with human peripheral blood mononuclear cells or purified T cells from a donor allogeneic to the artery 1 week before surgery. To compare rejection of injured versus healthy tissues, these manipulations were combined. Results were analyzed ex vivo by histology, morphometry, immunohistochemistry, and mRNA quantitation or in vivo by ultrasound. Our results showed that reperfusion injury, which otherwise heals with minimal sequelae, intensifies the degree of allogeneic T cell-mediated injury to human artery segments.

CONCLUSIONS

We developed a new human-mouse chimeric model demonstrating interactions of reperfusion injury and alloimmunity using human cells and tissues that may be adapted to study other forms of nonimmune injury and other types of adaptive immune responses.

[Lateral homodigital flaps pedicled with cutaneous branches of digital artery for repairing nail bed defects]

OBJECTIVE

To investigate the effectiveness of using lateral homodigital flaps pedicled with cutaneous branches of digital artery for repairing nail bed defects.

METHODS

Between December 2008 and July 2010, 5 patients with nail bed defects were repaired with lateral homodigital flaps pedicled with cutaneous branches of digital artery. Nail bed defects were caused by crush injury of machine. There were 3 males and 2 females, aged from 22 to 35 years (mean, 28 years). Injured fingers included 3 thumbs, 1 index finger, and 1 middle finger. The size of the defects ranged from 1.1 cm x 1.0 cm to 1.8 cm x 1.2 cm and the size of the flaps ranged from 2.7 cm x 1.3 cm to 3.1 cm x 1.7 cm. The donor sites were covered by skin graft. The time between injury and admission ranged from 1 hour and 12 minutes to 3 hours and 24 minutes (mean, 2.1 hours).

RESULTS

All flaps and skin grafts survived, and the incision healed by first intention. The follow-up time ranged from 6 to 9 months (mean, 7.5 months). The fingers had good appearance. Four cases gained full postoperative sensory recovery and the two-point discrimination was 4-5 mm at 3 months after operation, but it did not recover in 1 case at last follow-up. According to the functional assessment criteria of upper limb formulated by the Hand Surgery Branch of Chinese Medicine Association, the results were excellent in 4 cases and good in 1 case.

CONCLUSION

The lateral homodigital flaps pedicled with cutaneous branches of digital artery can repair nail bed defects without sacrifice of digital artery, and can gain a full sensory recovery. It is a feasible solution for treatment of nail bed defects especially for those unwilling to cause any damage to their toes.

[Short-term effectiveness of reverse island flap pedicled with terminal dorsal branch of digital artery with sense reconstruction for repairing fingertip defects]

OBJECTIVE

To investigate the method and effectiveness of repairing fingertip defects with reverse island flap pedicled with terminal dorsal branch of digital artery with sense reconstruction.

METHODS

Between December 2008 and March 2010, 32 patients (40 fingers) with fingertip defects were treated. There were 20 males (23 fingers) and 12 females (17 fingers), aged from 20 to 62 years (mean, 42 years). The time between injury and admission was from 1 to 8 hours. The injured fingers included thumb (2 cases), index finger (6 cases), index finger and middle finger (3 cases), middle finger (7 cases), middle finger and ring finger (3 cases), ring finger (8 cases), ring finger and little finger (2 cases), and little finger (1 case). The defect area ranged from 1.2 cm x 1.0 cm to 2.2 cm x 1.8 cm, and the flap area ranged from 1.5 cm x 1.0 cm to 2.5 cm x 2.0 cm. The fingertip defects were repaired by the reverse island flaps pedicled with terminal dorsal branch of digital artery and branch of digital nerve, and the branch of digital nerve was anastomosed with stump of proper digital nerve. The donor sites were repaired with free skin grafts.

RESULTS

Blisters occurred in 6 cases (9 fingers) and partial necrosis of the flaps in 2 cases (2 fingers), which were cured after symptomatic treatment. The other flaps and skin grafts survived and the wounds healed by first intention. Thirty cases (38 fingers) were followed up 6 months postoperatively. The shape, contour of the reconstructed fingertip, and motivation of the fingers were satisfactory. The superficial sensation and deep pain sensation recovered after 6 months of operation. The two-point discrimination was 4-6 mm in 24 fingers, 7-10 mm in 13 fingers, and none in 1 finger. According to the functional assessment criteria of upper limb formulated by the Hand Surgery Branch of Chinese Medical Association, S3 was achieved in 1 finger, S3+ in 13 fingers, and S4 in 24 fingers.

CONCLUSION

It is simple and safe to harvest the reverse island flap pedicled with terminal dorsal branch of digital artery with sense reconstruction; at the same time, the blood supply of the flap is reliable and its sense can be reconstructed. It is one of effective methods for repairing fingertip defects.

[Reverse island flap of digital artery parallel for repairing degloved injuries of fingertip]

OBJECTIVE

To investigate the effectiveness of reverse island flaps of digital artery parallel for repairing degloved injuries of the fingertip.

METHODS

Between June 2008 and January 2010, 13 cases of degloved injuries of the fingertip were treated. There were 8 males and 5 females with an average age of 34 years (range, 19-62 years). The causes of injuries were as follow: impact and press injury in 5 cases, wringer injury in 7 cases, and crush injury in 1 case. The injured fingers were comprised of index finger in 6 cases, middle finger in 4 cases, ring finger in 2 cases, and little finger in 1 case. The size of skin and soft tissue defect ranged from 2.0 cm x 1.8 cm to 3.0 cm x 2.5 cm. Three cases complicated by fracture of the distal phalanx, 1 case by rupture of the insertion of extensor tendon, and 1 case by rupture of the insertion of flexor tendon. The average time from injure to surgery was 4 hours (range, 1 hour and 30 minutes-12 hours). Two neighboring skin flaps located in the same course of digital artery were adopted to repair defect of the fingertip. The size of proximal skin flap ranged from 1.2 cm x 1.0 cm to 2.0 cm x 1.5 cm and the size of distal skin flap ranged from 1.1 cm x 1.0 cm to 1.5 cm x 1.3 cm. The free skin grafts were used to repair the donor sites.

RESULTS

Circulation crisis occurred in 1 case at 2 hours after operation and was eliminated by interval disconnecting. The other flaps and skin grafts survived and the wounds healed by first intention. The patients were followed up 6-18 months (mean, 10 months). All flaps presented the satisfactory appearance and texture, and the flexion and extension function of wounded fingers recovered to normal. Two-point discrimination ranged from 7 to 11 mm at last follow-up. According to the functional assessment criteria of upper limb formulated by the Hand Surgery Branch of Chinese Medical Association, the results were excellent in 9 cases, good in 3 cases, and fair in 1 case with an excellent and good rate of 92.3%.

CONCLUSION

Based on the anatomical features of communicating branches of distal interphalangeal joint, two neighboring flaps located in the same course of digital artery are adopted to repair soft tissue defect of the fingertip. This surgical method is a simple and effective method.

Effects of the ABO-mismatch between donor and recipient of cryopreserved arterial homografts

AIM

Cryopreserved arterial homograft (CAH) is a well-established substitute material for in situ reconstruction of vascular infections. However, their degeneration remains serious complication. Although several studies propose ABO-mismatching between CAH-donor and -recipient as the main reason, the results are controversial. We compared the outcome between ABO-compatible and ABO-incompatible CAH recipients to evaluate the contribution of ABO-mismatching.

METHODS

Between January 2004 and December 2007, a retrospective review in 32 patients who underwent CAH-implantation was performed. The patients were divided in ABO-incompatible (group A: 17/32 patients; 53%) and ABO-compatible (group B: 15/32 patients; 47%) to CAH donor. Leucocytes, platelets and C-reactive protein (CRP) levels were recorded during the in-hospital stay. These were correlated with the surface of implanted homograft (SIH). Mid-term survival- and freedom-from-reoperation (FFR) rates were also calculated.

RESULTS

In both groups, peak of leucocytes and CRP was recorded on third postoperative day (POD3) and regarding platelets lowest values on POD1. Interestingly, a second CRP-peak was reported on POD8 in group A (A: 172±104mg/L vs. B: 75±55mg/L, P=0.01). No relationship between second CRP-peak and SIH was found. After 27 months median follow-up (range, 5-49 months), survival- (65% vs. 84%, P=0.28) and FFR-rates (94% vs. 93%, P=0.98) remained comparable.

CONCLUSION

We consider that the second CRP-peak expresses an early cytoimmunologic response of ABO-incompatible recipients against CAH. However, we did not find any relationship between ABO-incompatibility and poor mid-term outcome in terms of reoperation or mortality. Longer surveillance of our patients is mandatory.

Good results in patients with defects after intraoral tumour excision using facial artery musculo-mucosal flap

INTRODUCTION

The purpose of this article was to assess our experience with the facial artery musculomucosal (FAMM) flap technique for reconstruction of the oral cavity after tumour ablation. We also introduce new surgical developments for this technique.

MATERIAL AND METHODS

We retrospectively examined 22 cases involving FAMM flap surgery during the period from July 2007 to December 2009, focusing on postoperative complications and flap survival. We describe a new method for closing the donor defect using the buccal fat pad, as well as a method for harvesting a broader flap than is traditionally described.

RESULTS

Among the 22 cases studies, seven (32%) experienced postoperative complications. However, 57% of these cases had undergone preoperative radiotherapy. The complications we observed included problems relating to integration, partial necrosis and bleeding. There were no reported complications relating to the donor site.

CONCLUSION

The FAMM flap is a suitable technique for reconstruction following tumour ablation. Our study also suggests that while preoperative radiotherapy is a contraindication for this treatment, neck dissection surgery is not.

[Reconstruction of large nasal defects with lateral nasal artery pedicled nasolabial flap]

OBJECTIVE

To evaluate the curative effect of the lateral nasal artery pedicled nasolabial flap for reconstruction of nasal defects.

METHODS

From August 2005 to March 2009, 12 cases of large nasal tip and alar defects were repaired with the lateral nasal artery pedicled nasolabial flap. There were 5 male patients and 7 female patients with a mean age of 48.6 years (range, 35-60 years). Five cases of nasal defects were caused by trauma and other defects were caused by excision of carcinoma or hemangioma; the courses of disease were 1 to 10 years and 3 months to 40 years, respectively. The nasal defect size ranged from 2.0 cm x 1.5 cm to 4.5 cm x 2.5 cm. All defects were reconstructed with lateral nasal artery pedicled nasolabial flap in 9 cases and with island flap in 3 cases. The flap size ranged from 2.5 cm x 2.0 cm to 7.0 cm x 3.0 cm. Five patients required cartilage grafts for alar rim support and the distal end of the nasolabial flap was thinned and folded to repair the nasal lining. The donor sites were sutured directly.

RESULTS

The mild venous stasis at the distal end of three island flaps occurred at 5-24 hours postoperatively and alleviated spontaneously. All flaps survived. Incision at donor and accepted sites healed by first intention. Flap revision was performed in 5 cases after 6-15 months because of mild swelling at the pedicles of skin flaps. All patients were followed up 8-24 months, with an average of 13 months. All patients achieved satisfactory results in nasal appearance, flap texture and color, and ventilatory function. No obvious scar was found at donor sites.

CONCLUSION

The nasolabial flap is an excellent choice for reconstruction of defects of nasal tip and ala.

[Neurovascular free flap based on dorsal branch of digital artery of ring finger for finger pulp defect]

OBJECTIVE

To investigate the surgical procedures and clinical outcomes of the neurovascular free flap based on dorsal branch of digital artery of ring finger graft for repair of finger pulp defect.

METHODS

From February 2006 to May 2009, 11 cases (11 fingers) of finger pulp defect with tendon and bone exposure were treated, including 8 males and 3 females with an average age of 29 years (range, 23-40 years). The defect locations were thumb in 2 cases, index finger in 5 cases, and middle finger in 4 cases. The defect size ranged from 1.0 cm x 1.0 cm to 2.5 cm x 2.0 cm. The time from injury to operation was 1-9 hours. The flap size ranged from 1.5 cm x 1.5 cm to 3.0 cm x 2.5 cm. Five flaps carried the dorsal branch of digital nerve, 6 flaps carried nervi digital dorsales. The flaps were cut from proximal radial dorsal ring finger in 4 cases and from proximal ulnar dorsal ring finger in 7 cases. Defect of donor site was repaired with full-thickness skin grafting.

RESULTS

All flaps and grafted skins survived; wound and incision of donor site achieved healing by first intention. Eleven patients were followed up 6 to 24 months with an average of 12 months. The other finger flaps had good texture and shape except for 1 flap with slightly bloated. The activities of finger distal interphalangeal joint were normal, the two-point discrimination of finger pulp was 7-12 mm. The extension and flexion activities of donor fingers were normal, the ringlike thread scar left at the donor site.

CONCLUSION

It is an ideal method to use the neurovascular free flap based on dorsal branch of digital artery of ring finger graft for repair of finger pulp defect, which has the advantages of simple operation, good appearance, and functional recovery.

Post-implant evaluation of the anastomotic biomechanical coupling between human native arteries and arterial cryografts implanted in lower-limb revascularization procedures

In the past, the reduced availability and problems with the preservation/storage limited the use of cryopreserved /defrosted arteries (cryografts) in lower limb revascularization procedures. However, the recent development of cryopreservation techniques enhanced cryografts availability and value, and renewed the interest in their use as vascular substitutes. Anyway, some issues related with the cryografts properties and with their usefulness remain to be clarified.

[Clinical experience with cold-preservation of venous and arterial allografts. long-term outcomes]

INTRODUCTION

Venous and arterial allografts extend the possibilities of peripheral arterial disease as well as vascular prosthesis infections treatment.

MATERIAL AND METHODS

Between 10/1997 and 1/2009 we used 112 allogeneic vessels (30 arteries, 82 veins) in 104 patients. Venous allografts were used for 82 reconstructions in 75 patients (M/F 41/34, aged 41-85 years, median 66 years) with critical limb ischemia and no suitable autogenous venous material. Arterial allografts were used in 9 patients (M/F 8/1, aged 56-77 years, median 63 years) with aortoiliac prosthetic infections or mycotic abdominal aortic aneurysms and in 20 transplanted patients (M/F 11/9, aged 32-67 years, median 56 years) with aortoiliac atherosclerotic disease.

RESULTS

Patients survival rate after allovenous bypasses was 92% at 1 year and 78% at 3 years. Limb salvage rate was 67% at 1 year and 53% and 3 years. Secondary patency rate was 48% at 1 year and 27% at 3 years. Patient survival rate after alloarterial bypasses was 86% at 1 year and 69% at 3 years. No signs of arterial grafts aneurysmal formation and no need for secondary intervention of any arterial reconstruction was observed during the follow up period in any patient after alloarterial transplantation.

CONCLUSIONS

Cold-stored venous and arterial allografts are suitable alternative conduits for limb salvage procedures, vascular prosthesis infections as well as for arterial reconstructions in transplanted patients.

Uruguayan experience with cryopreserved arterial homografts

INTRODUCTION

We analyzed the Uruguayan experience with cryopreserved arterial homografts. We studied 55 medical records in the period from June 9, 2000 to April 7, 2007, including 41 from males and 14 from females, ranging from 36-78 years of age. The clinical indications were as follows: Group 1, revascularization of infrainguinal atherosclerotic occlusive disease by bypass due to the lack of availability of a suitable vein (n = 35); Group 2, substitution of an infected prosthetic grafts (n = 15); and Group 3, arteriovenous fistula (AVF) after failure of previous prosthetic loops by repeated thrombosis and/or infection in the absence of a vein (n = 5).

RESULTS

Among Group 1, primary and secondary patency rates were 61% and 71%, respectively at 1 year with 15 complications, 3 infections, 8 thromboses, 2 aneurysms, 1 homograft degradation, and 1 death related to surgery. Among Group 2, the primary and secondary patency rates were 71% and 79%, respectively, at 1 year with 6 patients experiencing complications. Group 3 did not have complications with a primary patency rate of 67% at 1 year.

CONCLUSIONS

The use of cryopreserved arterial homografts is a valid, accessible, and safe alternative in complicated vascular situations. In our country, it is a technology to consider for patients with critical limb ischemia, when the risk of a major amputation is high and it is not possible to have a suitable vein or prosthetic bypass. It can be an excellent alternative for the substitution of infected synthetic bypasses, especially to substitute in situ for an infected aortic graft.

Arterial allograft allows in-line reconstruction of prosthetic graft infection with low recurrence rate and mortality

Surgical management of infected prosthetic vascular grafts is associated with a significant risk of recurrent infection, limb loss, and mortality. Treatment options include graft excision with extra-anatomic bypass and in-line repair with prosthetic graft, vein, or artery. We hypothesized that in-line reconstruction using cryopreserved arterial allografts would be associated with a lower recurrent infection rate, limb loss, and mortality than other alternatives. We reviewed all cases where adults underwent surgical management of infected prosthetic aortic, iliac, or femoral bypass grafts with cryopreserved arterial allograft at our medical center from 2001 to 2008. Cryopreserved arterial allografts were used in 21 patients. There were nearly equal number of men (n = 11, 52%) and women (n = 10, 48%). The median age was 63 years and median time since cryoartery repair was 4 years. There have been no deaths in the follow-up period. Complications (19%) included colon perforation (n = 1), lower extremity compartment syndrome (n = 1), limb ischemia (n = 1), and reinfection with pseudoaneurysm and subsequent limb amputation (n = 1). These positive findings of low morbidity and absence of mortality in high risk patients have resulted in a shift at our institution to the preferential use of cryopreserved arterial allograft with in-line reconstruction for infected prosthetic grafts.

Four-year outcome of OPCAB no-touch with total arterial Y-graft: making the best treatment a daily practice

BACKGROUND

A retrospective, single-center 4-year clinical study of the off-pump coronary artery bypass grafting no-touch technique with arterial conduits (Y-graft) was compared with the Syntax trial.

METHODS

Four hundred consecutive patients ("all-comers") who underwent coronary surgery between 2004 and 2008 at the Thorax Center Twente (TCT) formed the study group. The primary end point was in-hospital and 12-month major cardiovascular or cerebrovascular event (MACCE). Event rates of MACCE were based on life tables, and overall MACCE was determined by Kaplan-Meier analysis.

RESULTS

In-hospital mortality was 0.2%. Cumulative 1-year survival was 98.2%, and freedom from MACCE was 94.7% +/- 1.1%. Cumulative 4-year survival and freedom from MACCE were 91.2% +/- 2.4% and 82.1% +/- 3.0%, respectively. There were no significant differences in the baseline characteristics between the patients of the TCT group and the surgical arm of the Syntax trial. Repeat revascularization, MACCE, and symptomatic graft occlusion in the TCT group were significantly lower than in the Syntax trial. The event rate of myocardial infarction and all-cause death in the TCT group were significantly lower than those of the percutaneous coronary intervention arm of the Syntax trial. There was a clear trend toward a reduction of the event rate of stroke in the TCT group (0.8%) compared with the surgical arm of the Syntax trial (2.2%). There was no significant difference of stroke rate between the TCT group and the percutaneous coronary intervention arm of the Syntax trial.

CONCLUSIONS

A state-of-the-art surgical technique such as off-pump coronary artery bypass grafting no-touch can further improve the advantage of surgical treatment with respect to percutaneous coronary intervention. Off-pump coronary artery bypass grafting no-touch surgery can be the treatment of choice for patients with three-vessel disease and left main stenosis.

[Applied anatomy of medial plantar artery combined flaps and repairing heel and adjacent vast soft tissue defects]

OBJECTIVE

To explore an anatomical basis and incising scope for the medial plantar artery combined flaps and its feasibility of repairing heel and adjacent vast soft tissue defects.

METHODS

The origin, branches, course and distribution of the medial plantar artery were studied in 20 legs of adult cadavers. The largest area of healthy adult's medial plantar and medialis pedis scope that could be incised for the combined flap was measured. Ten cases of heel and adjacent vast soft tissue defects were repaired by the combined medial plantar and medialis pedis flaps. Age range 28-60 years old. The areas of flaps were 9 cm x 7 cm - 10 cm x 8 cm. Defects of tendo calcaneus were repaired by the tendon of abductor muscle and plantar fascia in 3 cases with skin grafts on the donor sites.

RESULTS

The medial plantar artery gave off deep branch (diameter: 1.5 mm +/- 0.3 mm) and superficial branch (diameter: 1.0 mm +/- 0.2 mm). The length of media plantar artery deep branch was (8.9 +/- 0.2) cm and gave off 3-5 cutaneous branches. The largest area of combined flap was about 10.4 cm x 9.2 cm - 9.1 cm x 8.2 cm. Ten flaps survived completely. Eight flaps were followed up for 1 month to 1.5 years. The color, texture and appearance of flaps were excellent. The flaps of two-point discrimination were not different with opposite medial region. The affected limb exercised freely and had no ulceration on the flap.

CONCLUSIONS

The combined flap has a reliable blood supply and it can recover good sensation after operation. It is one of ideal flaps to repair heel and adjacent vast soft tissue defects. Its disadvantage is a complicated operation.

[Reliability of venae comitant of facial artery as the donor vein in microvascular autologous submandibular gland transfer]

OBJECTIVE

To analyse the reliability of concomitant venae of facial artery as the donor vein in microvascular autologous submandibular gland transfer.

METHODS

One hundred and seventeen cases with severe keratoconjunctivitis sicca treated by microvascular transfer of autogenous submandibular gland transfer from August of 1999 to November of 2007 were reviewed. The cases were divided into three groups according to their different donor veins, with group A using facial veins, group B using concomitant venae of facial artery, and group C using a vein near the duct. Group A and B were compared in terms of venous thrombosis rate and failure rate related to venous thrombosis.

RESULTS

Among 117 cases, there were 122 sides of submandibular gland transfers, with 93 in group A, 27 in group B, and 2 in group C. Postoperative venous thromboses rate was 15% in group A and 7% in group B, with significant difference (P < 0.01). The failure rate of transferred gland related to venous thrombosis was 8% in group A, and 7% in group B, with no significant difference (P > 0.05).

CONCLUSIONS

Concomitant venae of facial artery can be used as reliable donor vein in microvascular autologous submandibular gland transfer.

[Repair of small and medium-sized soft tissue defect in ankle with sural neurocutaneous vascular flap pedicled on main perforating branch of peroneal artery]

OBJECTIVE

To investigate the operative techniques and clinical results of sural neurocutaneous vascular flap pedicled on the relatively higher and main perforating branch of peroneal artery in repairing small and medium-sized soft tissue defects in ankle.

METHODS

From July 2004 to February 2007, 14 patients (9 males and 5 females, aged 19-53 years) with small and medium-sized soft tissue defects in ankle were treated, including 4 cases of skin necrosis caused by surgery for achilles tendon rupture, 3 soft tissue defects due to car accident, 2 crush injury due to falling heavy objects, 2 chronical infectious ulcer, 2 skin necrosis caused by surgery for calcaneus fracture and 1 melanoma resection in heel. Ranging from 4 cm x 2 cm to 9 cm x 5 cm and combing with exposure of either tendon or bone, the defects were in ankle areas (12 cases) and weight-bearing heel (2 cases). The time from injury to hospitalization was 12 days to 13 months, except 3 cases of emergency hospitalization. After thorough debridement, the sural neurocutaneous vascular flaps (13 cm x 5 cm - 36 cm x 6 cm ) pedicled on the perforating branch of peroneal artery was harvested to repair the defects. The donor sites were sutured directly.

RESULTS

Postoperatively all the flaps survived, and all the donor sites and wounds healed by first intention. Over a 7-23 month follow-up period, the texture, appearance and color of the flaps in all cases were good, with two-point discrimination of 7-12 mm.The function of ankle obtained satisfactory recovery with normal in-shoe gait.

CONCLUSION

With a reliable blood supply, simple operative procedure, sound repair of wound and satisfactory recovery of limb function, the sural neurocutaneous vascular flap pedicled on the relatively higher and main perforating branch of peroneal artery is applicable for the repair of small and medium-sized defects in the ankle and weight-bearing area of heel, especially for patients who have no satisfactory perforating branch in lower position.

[The use of a synthetic vascular artificial prosthesis or arterial homograft in cases of patients with the arteriosclerosis and terminal insufficiency of kidney cured by the kidney transplantation]

Arterial transplantations were practiced in the vascular surgery since the beginning of her formation but without successes in the distant observation. Transplantation of a kidney is a routine conduct in the treatment of the decadent incapacity of a kidney. The dissertation concerns a use of arterial allografts kept using a method of a cold ischaemia in the protective liquid or synthetic vascular dacron artificial limbs or PTFE used as arterial foot-bridges at patients with the atherosclerotic obstruction aortal-pelvic, treated with the kidney transplantation. The arterial transplant is created from the aorta, arteria iliacas common and externa, femoral arteries common and superficial. A tissue material is kept using the method of the cold ischaemia and practical as the aortal foot-bridge-femoral or aortal-two-femoral at classified earlier patients being subjecteds to transfusion. The other way of a transplantation of a kidney at patients with the arteriosclerosis is the realization earlier or one-temporarily the vascular foot-bridge with use of the synthetic artificial limb. It seems that vascular artificial limbs about enlarged resistance on the contagion should be used in such a case. Sonographic examinations with duplex doppler and angiography are performed in all cases. The analysis of such cures can make a creation of the most profitable algorithm of the conduct possible in cases of patients suffering from ischaemia of lower limbs and requiring a transplantation of a kidney because of its incapacity.

Reduced antigenicity of formaldehyde-fixed arterial allografts and their potential clinical application

This study was performed to examine the antigenicity of formaldehyde-fixed arterial allografts and their potential clinical application for hemodialysis access. Human femoral arteries were fixed with formaldehyde. New Zealand white rabbits were immunized with antigens prepared from fixed or unfixed grafts followed by anti-serum collection. The antigenicity of fixed grafts was evaluated using double-diffusion in two dimensions. Seventy-six fixed allografts were transplanted into 50 patients with end-stage renal diseases as hemodialysis access and monitored for acute rejection, blood flow, and patency rates. Anti-HLA antibody was evaluated using a panel-reactive antibody (PRA) assay in 6 patients. Formaldehyde-fixed grafts demonstrated reduced antigenicity as determined using double-diffusion in two dimensions when compared with unfixed grafts. Histological evaluation of allografts demonstrated absence of cell-mediated acute rejection after transplantation. Allografts demonstrated satisfactory blood flow with primary and secondary patency rates at 1, 2, and 3 years after allotransplantation. Serum collected from 6 patients after transplantation (mean, 3.3 +/- 3.2 years) did not demonstrate increased anti-HLA antibody levels. The allograft intimal hyperplasia was characterized by proliferation of actin-expressing smooth muscle cells. This study demonstrated that formaldehyde fixation reduced the antigenicity of arterial allografts. Acute rejection was absent after allotransplantation. The lack of increased PRA levels after allotransplantation suggested that allo-sensitization is not induced by fixed allografts. The use of formaldehyde-fixed allografts as hemodialysis access demonstrated blood flow and patency rates. Intimal hyperplasia of allografts is characterized by proliferation of actin-expressing cells. Our results supported the clinical use of formaldehyde-fixed arterial allografts for hemodialysis access.