Contemporary outcomes for arterial reconstruction with non-saphenous vein cryo-preserved conduits

OBJECTIVE

Cryopreserved (CP) products are utilized during challenging cases when autogenous or prosthetic conduit use is not feasible. Despite decades of experience with cadaveric greater saphenous vein (GSV), there is limited available data regarding the outcomes and patency of other CP products, specifically arterial and deep venous grafts. This study was designed to evaluate outcomes of non-GSV CP conduits in patients undergoing urgent, emergent, and elective arterial reconstruction at our institution. We hypothesized that non-GSV CP allografts have adequate patency and outcomes and are therefore a feasible alternative to GSV in settings where autologous graft is unavailable or prosthetic grafts are contraindicated.

METHODS

This study was approved by the Institutional Review Board at our institution. We retrospectively reviewed charts of patients undergoing arterial reconstructions using CP conduits from 2010 to 2022. Data collected included demographics, comorbidities, smoking status, indications for surgery, indication for CP conduit use, anatomic reconstruction, urgency of procedure, and blood loss. Time-to-event outcomes included primary and secondary graft patency rates, follow-up amputations, and mortality; other complications included follow-up infection/reinfection and 30-day complications, including return to the operating room and perioperative mortality. Time-to-event analyses were evaluated using product-limit survival estimates.

RESULTS

Of 96 identified patients receiving CP conduits, 56 patients received non-GSV conduits for 66 arterial reconstructions. The most common type of non-GSV CP product used was femoral artery (31 patients), followed by aorto-iliac artery (22 patients), and femoral vein (19 patients), with some patients receiving more than one reconstruction or CP product. Patients were mostly male (75%), with a mean age of 63.1 years and a mean body mass index of 26.7 kg/m2. Indications for CP conduit use included infection in 53 patients, hostile environment in 36 patients, contaminated field in 30 patients, tissue coverage concerns in 30 patients, inadequate conduit in nine patients, and patient preference in one patient. Notably, multiple patients had more than one indication. Most surgeries (95%) were performed in urgent or emergent settings. Supra-inguinal reconstructions were most common (53%), followed by extra-anatomic bypasses (47%). Thirty-day mortality occurred in 10 patients (19%). Fifteen patients (27%) required return to the operating room for indications related to the vascular reconstructions, with 10 (18%) cases being unplanned and five (9%) cases planned/staged. Overall survival at 6, 12, and 24 months was 80%, 68%, and 59%, respectively. Primary patency at 6, 12, and 24 months was 86%, 70%, and 62%, respectively. Amputation freedom at 6 months, 12 months, and 24 months was 98%, 95%, and 86%, respectively for non-traumatic indications.

CONCLUSIONS

Non-GSV CP products may be used in complex arterial reconstructions when autogenous or prosthetic options are not feasible or available.

Two-step arterial reconstruction technique for en bloc resection of a large retroperitoneal liposarcoma involving the common iliac artery

Retroperitoneal liposarcoma (RPLS) is a rare but challenging neoplasm, which is frequently associated with iliac vessel invasion. We describe how we used a two-step arterial reconstruction technique to perform en bloc resection of a large RPLS involving the iliac arteries in three patients. A temporal long in situ graft bypass was established using a prosthetic vascular graft during dissection of the tumor. This bypass provided an unobscured surgical field, while maintaining blood flow in the lower limb during the operation. After removal of the tumor and washing out the abdominal cavity, the new prosthetic vascular graft of a suitable length was placed. No graft-related complications, including vascular graft infection or graft occlusion, occurred during the follow-up period. This novel technique appears to provide a safe and effective way to remove large RPLSs involving the retroperitoneal major vessels.

The Human Acellular Vessel (HAV) as a vascular conduit for infrainguinal arterial bypass

Autologous vein is the optimal conduit for peripheral arterial bypass surgery, a standard recently highlighted by findings from the BEST-CLI trial. The Human Acellular Vessel is a novel biologic conduit produced using regenerative medicine technologies with structural and mechanical properties like a human blood vessel. Not yet approved by the United States Food and Drug Administration, the Human Acellular Vessel is being studied as an alternative bypass conduit in patients with peripheral arterial disease, vascular injury, and those in need of arteriovenous access for hemodialysis. This report describes and illustrates the technical aspects of intraoperative handling specific to the use of this new and innovative technology.

Six-year outcomes of a phase II study of human-tissue engineered blood vessels for peripheral arterial bypass

Objective

The human acellular vessel (HAV) was evaluated for surgical bypass in a phase II study. The primary results at 24 months after implantation have been reported, and the patients will be evaluated for ≤10 years.

Methods

In the present report, we have described the 6-year results of a prospective, open-label, single-treatment arm, multicenter study. Patients with advanced peripheral artery disease (PAD) requiring above-the-knee femoropopliteal bypass surgery without available autologous graft options had undergone implantation with the HAV, a bioengineered human tissue replacement blood vessel. The patients who completed the 24-month primary portion of the study will be evaluated for ≤10 years after implantation. The present mid-term analysis was performed at the 6-year milestone (72 months) for patients followed up for 24 to 72 months.

Results

HAVs were implanted in 20 patients at three sites in Poland. Seven patients had discontinued the study before completing the 2-year portion of the study: four after graft occlusion had occurred and three who had died of causes deemed unrelated to the conduit, with the HAV reported as functional at their last visit. The primary results at 24 months showed primary, primary assisted, and secondary patency rates of 58%, 58%, and 74%, respectively. One vessel had developed a pseudoaneurysm deemed possibly iatrogenic; no other signs of structural failure were reported. No rejections or infections of the HAV occurred, and no patient had required amputation of the implanted limb. Of the 20 patients, 13 had completed the primary portion of the study; however, 1 patient had died shortly after 24 months. Of the remaining 12 patients, 3 died of causes unrelated to the HAV. One patient had required thrombectomy twice, with secondary patency achieved. No other interventions were recorded between 24 and 72 months. At 72 months, five patients had a patent HAV, including four patients with primary patency. For the entire study population from day 1 to month 72, the overall primary, primary assisted, and secondary patency rate estimated using Kaplan-Meier analysis was 44%, 45%, and 60% respectively, with censoring for death. No patient had experienced rejection or infection of the HAV, and no patient had required amputation of the implanted limb.

Conclusions

The infection-resistant, off-the-shelf HAV could provide a durable alternative conduit in the arterial circuit setting to restore the lower extremity blood supply in patients with PAD, with remodeling into the recipient's own vessel over time. The HAV is currently being evaluated in seven clinical trials to treat PAD, vascular trauma, and as a hemodialysis access conduit.

Clinical significance of variant hepatic artery in pancreatic resection: A comprehensive review

The anatomical structure of the pancreaticoduodenal region is complex and closely related to the surrounding vessels. A variant of the hepatic artery, which is not a rare finding during pancreatic surgery, is prone to intraoperative injury. Inadvertent injury to the hepatic artery may affect liver perfusion, resulting in necrosis, liver abscess, and even liver failure. The preoperative identification of hepatic artery variations, detailed planning of the surgical approach, careful intraoperative dissection, and proper management of the damaged artery are important for preventing hepatic hypoperfusion. Nevertheless, despite the potential risks, planned artery resection has become acceptable in carefully selected patients. Arterial reconstruction is sometimes essential to prevent postoperative ischemic complications and can be performed using various methods. The complexity of procedures such as pancreatectomy with en bloc celiac axis resection may be mitigated by the presence of an aberrant right hepatic artery or a common hepatic artery originating from the superior mesenteric artery. Here, we comprehensively reviewed the anatomical basis of hepatic artery variation, its incidence, and its effect on the surgical and oncological outcomes after pancreatic resection. In addition, we provide recommendations for the prevention and management of hepatic artery injury and liver hypoperfusion. Overall, the hepatic artery variant may not worsen surgical and oncological outcomes if it is accurately identified pre-operatively and appropriately managed intraoperatively.

The influence of socioeconomic status on outcomes of lower extremity arterial reconstruction

OBJECTIVE

Although it has been shown that patient socioeconomic status (SES) is associated with the surgical treatments chosen for severe peripheral arterial disease (PAD), the association between SES and outcomes of arterial reconstruction have not been well-studied. The objective of this study was to determine if SES is associated with outcomes following lower extremity arterial reconstruction.

METHODS

Patients 40 years and older who had surgical revascularization for severe lower extremity PAD were identified in the Nationwide Readmissions Database, 2010 to 2014. Measures of SES including median household income (MHI) quartiles of patients' residential ZIP codes were extracted. Factors associated with repeat revascularization, subsequent major amputations, hospital mortality, and 30-day all-cause readmission were evaluated using multivariable regression analyses.

RESULTS

Of the 131,529 patients identified, the majority (61%) were male, and the average age was 69 years. On unadjusted analyses, subsequent amputations were higher among patients in the lowest MHI quartile compared with patients in the highest MHI quartile (13% vs 10%; overall P < .001). On multivariable analyses, compared with patients in the lowest quartile, those in the highest quartile had lower amputation (adjusted odds ratio [aOR], 0.70; 95% confidence interval (CI), 0.63-0.77; overall P < .001) and readmission (aOR, 0.91; 95% CI, 0.84-0.99; overall P = .028) rates. However, subsequent revascularization (aOR, 1.04; 95% CI, 0.94-1.15) and mortality (aOR, 1.01; 95% CI, 0.79-1.28) rates were not different across the groups.

CONCLUSIONS

Lower SES is associated with disproportionally worse outcomes following lower extremity arterial reconstruction for severe PAD. These data suggest that improving outcomes of lower extremity arterial reconstruction may involve addressing socioeconomic disparities.

Conversion pancreaticoduodenectomy with dual arterial reconstructions for locally advanced pancreatic cancer: Case report and literature review

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Transection of the celiac artery is often not justified in pancreaticoduodenectomy.

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Reconstruction of the splenic and hepatic arteries might resolve this situation.

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Great saphenous vein graft may be a conduit for non-anatomical arterial inflow.

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Reconstruction of the splenic artery could enable preservation of the stomach.

Introduction

Extended pancreatectomy for initially unresectable locally advanced (URLA) pancreatic carcinoma (PC) often requires combined arterial resection/reconstruction. By limiting candidate arterial inflow after combined resection of the celiac arterial system over a long distance, great saphenous vein graft (GSVG) is an alternative conduit for obtaining non-anatomical arbitrary arterial inflow.

Presentation of case

A 66-year-old woman was diagnosed with URLA pancreatic head carcinoma involving the region from the celiac axis (CA) to the common hepatic and proximal splenic artery (SA). She received 10 courses of modified FOLFIRINOX followed by concurrent chemoradiotherapy including S1 with favorable response. The duration of disease control and normalization of serum carbohydrate antigen 19−9 (CA19−9) exceeded 10 months, and conversion surgery was planned. Extended pancreaticoduodenectomy (PD) required concomitant resection of the CA to the proper hepatic and SA. The dual arterial reconstructions involved a GSVG interposition from the abdominal aorta to the distal SA to preserve the entire stomach, and from the mesenteric second jejunal artery to the right hepatic artery. The patient achieved pathological R0 resection with a histological response of Evans grade IIB.

Discussion

Reconstruction of the distal SA with GSVG in extended PD enabled preservation of the subtotal stomach and distal pancreas, even when the root of the CA was transected.

Conclusion

Multiple arterial reconstructions using GSVG might be useful in extended pancreatectomy to preserve visceral organs, offer better quality of life in terms of oral intake and nutritional status, and control blood glucose than after total pancreatectomy concomitant with subtotal gastrectomy.

Recurrent brachial artery aneurysm repair in a child managed with Gore-Tex conduit reinforcement

Pediatric nonaortic arterial aneurysms are uncommon diagnoses and can be affiliated with underlying conditions, which include neurofibromatosis I, Ehlers-Danlos type IV syndrome, Kawasaki disease, Marfan syndrome, and Loeys-Dietz, polyarteritis nodosa, as well as Klippel-Trenauny syndrome. The standard of care has been early surgical excision and arterial reconstruction when indicated. This report details a case of recurrent brachial artery aneurysm in a 2-year-old boy despite multiple attempts at excision and reconstruction. Such recurrences were seen as rapidly as 3 months postoperatively. Ultimately, a Gore-Tex conduit was used to reinforce a reversed saphenous vein graft repair. There has been no evidence of recurrent disease during the 18-month follow-up period.

Back-table surgery pancreas allograft for transplantation: Implications in complications

To describe the main aspects of back-table surgery in pancreatic graft and the problems arising from poor technique. Back-table surgery for pancreatic graft is a complex, meticulous and laborious technique on which the success of implant surgery and perioperative results depends. The technique can be described in the following steps: Preparation of the sterile table, ex-situ inspection of the pancreas-spleen block, management of the duodenum, identification of the bile duct, preparation of the portal vein, preparation of the own graft arteries and anastomosis to the arterial graft, spleen management and graft preservation prior to implantation in the recipient. A careful inspection of the pancreas-spleen block should be performed. It is important to identify the stump of the main bile duct, the portal vein cuff, and the arrangement of the superior mesenteric artery and splenic artery. The redundant duodenum must be removed. The availability of a good venous cuff facilitates the portal vein anastomosis and the positioning of the graft, two key points to prevent thrombosis. The section line of the arteries must be clean, without atherosclerosis, to prevent arterial thrombosis. The superior and splenic mesenteric arteries are generally separated by dense fibrolymphatic tissue. The artery can be reconstructed by interposing a "Y" graft from the donor iliac artery; or with an end-to-end anastomosis between the splenic artery and the superior mesenteric artery. An exquisite technique of bench work helps to prevent the most feared complications of pancreas transplantation: Thrombosis and graft pancreatitis.

Successful conversion surgery of distal pancreatectomy with celiac axis resection (DP-CAR) with double arterial reconstruction using saphenous vein grafting for locally advanced pancreatic cancer: a case report

Background

Pancreatic cancer is a disease with a poor prognosis, requiring multidisciplinary treatment combining chemotherapy and surgery for effective management. Distal pancreatectomy with celiac axis resection (DP-CAR) is a surgical intervention performed for locally advanced pancreatic cancer, but the benefit of arterial reconstruction in DP-CAR is unclear.

Case presentation

A 49-year-old man with pancreatic cancer was referred to our hospital. Imaging revealed a 54-mm tumor mainly in the pancreatic body, but with arterial infiltration including into the celiac, common hepatic, left gastric, splenic and gastroduodenal arteries. Distant metastases were not detected. The patient was diagnosed with unresectable locally advanced pancreatic cancer and chemoradiotherapy was planned. Three cycles of gemcitabine (1000 mg/m²) plus nab-paclitaxel (125 mg/m²) every 4 weeks were followed by irradiation (2 Gy/day, total 50 Gy over 25 days) together with S-1 administration (80 mg/m²/day). A partial response (PR) according to Response Evaluation Criteria in Solid Tumors (RECIST) was achieved, so surgical intervention was considered. Because the tumor had invaded the root of the gastroduodenal artery, we performed DP-CAR with resection of the gastroduodenal artery, followed by arterial reconstruction of the proper hepatic and left gastric arteries, anastomosed with the abdominal aorta using a great saphenous vein graft in the shape of a “Y”. Histopathology showed that 60% of tumor cells were destroyed by the chemoradiotherapy, defined as grade IIb in the Evans classification. No malignancy was detected at the surgical margin, including the celiac artery, gastroduodenal artery or pancreatic stump; thus R0 surgery was successful. S-1 (80 mg/day) was administered as adjuvant chemotherapy for 6 months. The patient is now doing well without recurrence for > 2 years after the initial treatment (more than 16 months after surgery).

Conclusion

For locally advanced pancreatic cancer, multidisciplinary treatment combining gemcitabine/nab-paclitaxel-based chemoradiotherapy and then DP-CAR surgery with gastroduodenal artery resection and arterial reconstruction using saphenous vein grafting enabled R0 resection in this patient and led to a favorable long-term prognosis.

Kidney transplantation from living donor with monolateral renal artery fibromuscular dysplasia using a cryopreserved iliac graft for arterial reconstruction: a case report and review of the literature

Background

Aging and mortality of patients on waiting lists for kidney transplantation have increased, as a result of the shortage of organs available all over the world. Living donor grafts represent a significant source to maintain the donor pool, and resorting successfully to allografts with arterial disease has become a necessity. The incidence of renal artery fibromuscular dysplasia (FMD) in potential living renal donors is reported to be 2–6%, and up to 4% of them present concurrent extra-renal involvement.

Case presentation

We present a case of renal transplantation using a kidney from a living donor with monolateral FMD. Resection of the affected arterial segment and its subsequent replacement with a cryopreserved iliac artery graft from a deceased donor were performed. No intraoperative nor post-operative complications were reported. The allograft function promptly resumed, with satisfying creatinine clearance, and adequate patency of the vascular anastomoses was detected by Doppler ultrasounds.

Conclusion

Literature lacks clear guidelines on the eligibility of potential living renal donors with asymptomatic FMD. Preliminary assessment of the FMD living donor should always rule out any extra-renal involvement. Whenever possible, resection and reconstruction of the affected arterial segment should be taken into consideration as this condition may progress after implantation.

Superficial femoral artery pseudoaneurysm caused by a solitary femoral shaft osteochondroma in a young adult

We discuss the presentation, diagnosis, and surgical management of a young man presenting with a symptomatic superficial femoral artery pseudoaneurysm caused by a solitary femoral shaft osteochondroma. We review the existing literature regarding the incidence and management of this problem.

Arterial reconstruction using the donor's gonadal vein in living renal transplantation with multiple renal arteries: a case report and a literature review

Background

Arterial reconstruction is one of the paramount procedures in kidney transplantation (KT) and greatly important if the procured kidney has multiple renal arteries (MRA). Despite various established techniques for arterial reconstruction, sometimes, the surgeon finds performing arterial anastomoses challenging in case of MRA. In our case, the donor’s gonadal vein and recipient’s internal iliac artery graft were used for arterial anastomoses, and 3 years after KT, the allograft did not present vascular complications.

Case presentation

A 34-year-old man underwent ABO-incompatible preemptive living KT. The allograft had three renal arteries and four renal veins. After donor nephrectomy, arterial reconstruction was performed on a back table. These arteries were reconstructed into one piece using the recipient’s internal iliac artery graft. The two arteries at the middle of the renal hilum were reconstructed using the conjoined method. As the superior renal artery was too short to anastomose, the donor’s gonadal vein was used for extension. The internal iliac artery graft was anastomosed to the original internal iliac artery. Intraoperative Doppler ultrasonography revealed that the blood flow in each renal artery was adequate, resulting in sufficient blood flow throughout the allograft. The allograft function was maintained with a serum creatinine level of approximately 0.9 mg/dL without vascular complications 3 years after KT.

Conclusions

The donor’s gonadal vein can be a candidate for extension of the renal artery in the allograft with MRA. Further follow-up is needed for the assessment of long-term outcomes.

An original external iliac artery reconstruction with internal iliac artery translocation in a blunt injury of the pelvic vessels in a 4-year-old child: A 12-year follow-up study

A 4-year-old child presented to the emergency department with an open-book pelvic fracture, blunt trauma to the right external iliac artery and vein, and contaminated abdomen due to jejunal tear. Arterial reconstruction with polytetrafluoroethylene was not considered because of caliber discrepancy of 6 mm compared with 3 mm of the child's external iliac artery and a 40% probability of graft infection. We used the ipsilateral internal iliac artery, which was dissected for 7 cm; the distal artery was translocated and anastomosed to the distal external iliac artery. At 12 years of follow-up, the artery grew with the patient, with no need for replacement.

A rare anastomosis between the root of common hepatic artery and proper hepatic artery: implications for pancreaticoduodenectomy

BACKGROUND

Hepatic artery anomalies are often observed, and the variations are wide-ranging. We herein report a case of pancreatic cancer involving the common hepatic artery (CHA) that was successfully treated with pancreaticoduodenectomy (PD) without arterial reconstruction, thanks to anastomosis between the root of CHA and proper hepatic artery (PHA), which is a very rare anastomotic site.

CASE PRESENTATION

A 78-year-old woman was referred to our department for the examination of a tumor in the pancreatic head. Contrast-enhanced computed tomography (CT) revealed a low-density tumor of 40 mm in diameter located in the pancreatic head. The involvement of the common hepatic artery (CHA), the root of the gastroduodenal artery (GDA), and portal vein was noted. Although such cases would usually require PD with arterial reconstruction of the CHA, it was thought that the hepatic arterial flow would be preserved by the anastomotic site between the root of the CHA and the PHA, even if the CHA was dissected without arterial reconstruction. PD with dissection of the CHA and PHA was safely completed without arterial reconstruction, and sufficient hepatic arterial flow was preserved through the anastomotic site between the CHA and PHA.

CONCLUSION

We presented an extremely rare case of an anastomosis between the CHA and PHA in a patient with pancreatic cancer involving the CHA. Thanks to this anastomosis, surgical resection was successfully performed with sufficient hepatic arterial flow without arterial reconstruction.

Arterial reconstruction with donor iliac vessels during kidney transplantation in a patient with severe atherosclerosis

Atherosclerosis is common in patients with end-stage renal disease. Severe calcification of the iliac vessels is expected in the growing pool of kidney transplant candidates. Thus, transplant surgeons must constantly develop alternative operative strategies to deal with the technical challenges that this condition confers. This case report aims to highlight a reconstructive vascular technique to salvage a completely calcified recipient external iliac artery using a deceased donor's arterial iliac allograft from the same donor as the renal allograft in a 59-year-old man, as an effective method to decrease vascular complications.

Occipital artery to extracranial vertebral artery anastomosis for bilateral vertebral artery stenosis at the origin: A case report

BACKGROUND

Revascularization of posterior circulation is essential in patients with severe bilateral vertebral artery (VA) stenosis despite administering maximal medical treatment, due to the high mortality of posterior circulation stroke.

CASE DESCRIPTION

We present a 69-year-old man with bilateral severe VA stenosis at the origins, treated with occipital artery (OA)-distal VA anastomosis.

CONCLUSION

Endovascular treatment and other surgical treatments, such as bypass grafting, are effective, but OA-VA anastomosis is a safe and effective procedure for revascularization of the posterior circulation.

Distal Pancreatectomy with Celiac Axis Resection Combined with Reconstruction of the Left Gastric Artery

Distal pancreatectomy with celiac axis resection is one of the most aggressive approaches for the treatment of locally advanced pancreatic cancer with common hepatic artery and/or celiac axis invasion. However, ischemic complications such as ischemic gastropathy and liver failure are problematic. To avoid these complications, we developed left gastric artery-reconstructing distal pancreatectomy with celiac axis resection. We used the middle colic artery for reconstruction. We performed this procedure in 10 patients, using the middle colic artery in three different ways: left branch reconstruction, right branch reconstruction, and reverse reconstruction. On postoperative images, 90% of the reconstructed left gastric arteries were patent. No complications associated with arterial reconstruction occurred. No patients developed ischemic gastropathy or liver failure. The R0 resection rate was 70%. Nine patients underwent adjuvant chemotherapy and seven patients were able to start it within 90 days. Distal pancreatectomy with celiac axis resection combined with reconstruction of the left gastric artery using the middle colic artery is a feasible option and would enhance the safety for carefully selected patients. Multicenter validation is needed to clarify the benefits of this new procedure.

Management of Type 9 Hepatic Arterial Anatomy at the time of Pancreaticoduodenectomy: Considerations for Preservation and Reconstruction of a Completely Replaced Common Hepatic Artery

Recognition and management of aberrant hepatic arterial anatomy for patients undergoing pancreaticoduodenectomy (PD) are critical to ensure safe completion of the operation. When the common hepatic artery (CHA) is noted to emanate from the superior mesenteric artery (Michels' type 9 variant), it is vulnerable to injury during the dissection required for PD. While this anatomy does not preclude an operation, care must be taken to avoid injury, often by identifying the CHA throughout its entire course before beginning the dissection of the portal venous structures. The oncologic principle that cautions against resection of a pancreatic cancer when it involves the CHA in its standard position may not universally apply to tumors that focally involve the CHA in the type 9 anatomic variant. In highly selected patients, surgical resection may be entertained as disease biology may be analogous to local involvement of the gastroduodenal artery in a patient with standard anatomy. Here, we review the indications, techniques, and outcomes associated with arterial resection and reconstruction during pancreatectomy among patients with a pancreatic tumor involving a common hepatic artery arising from the superior mesenteric artery.

Two-step hepatic artery reconstruction for a hepatic artery lacking in length for the use of a microclamp in living donor liver transplantation

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A graft hepatic artery we experienced too short to rotate a microclamp in living donor liver transplantation.

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We performed two-step hepatic artery reconstruction.

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In the first step, we cut the recipient right hepatic artery and used it as an arterial graft.

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The graft hepatic artery was coapted to the distal stump of the arterial graft without a microclamp.

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In the second step, the proximal stump of the arterial graft was coapted to the recipient right hepatic artery.

Introduction

We describe successful two-step hepatic artery reconstruction in a patient whose graft site hepatic artery was too short for the use of a microclamp in living donor liver transplantation.

Presentation of case

A 57-year-old woman was diagnosed as having hepatitis C and liver cirrhosis. Her 26-year-old son was the living liver donor. The living donor underwent right lobectomy. The dissected graft hepatic artery was too short for the use of a microclamp. The recipient right hepatic artery was cut and used as an arterial graft. The graft right hepatic artery was sutured to the right hepatic artery of the arterial graft and the graft posterior branch of the right hepatic artery was sutured to the middle hepatic artery of the arterial graft. After reconstruction of the portal vein and hepatic vein was completed, anastomosis was performed between the graft right hepatic artery and right hepatic artery. The patency of the vessels was checked using color Doppler ultrasonography for 1 week postoperatively. No postoperative complications involving blood flow of the hepatic artery were observed.

Discussion

In our case, the recipient hepatic artery was cut and used as an arterial graft. Although the number of anastomotic sites of the hepatic artery increased, we could perform hepatic artery reconstruction safely and easily.

Conclusion

Two-step hepatic artery reconstruction is a useful method in cases where the recipient hepatic artery does not have enough length.

Total Pancreatectomy with Celiac Axis Resection and Hepatic Artery Restoration Using Splenic Artery Autograft Interposition

Although the indication of locally advanced pancreatic cancer with arterial involvement is controversial, the outcome of the patients with such disease treated by combined resection and reconstruction of the invaded artery has improved recently. For pancreatic body carcinoma invading the celiac axis, distal pancreatectomy with celiac axis resection has been safely performed. However, in case of pancreatic body carcinoma with involvement of the celiac axis, the common hepatic artery and the gastroduodenal artery, margin-negative resection requires total pancreatectomy with celiac axis resection and restoration of hepatic arterial flow. Here, we describe an interposition grafting technique using the splenic artery harvested from the resected specimen. This technique is effective and may widen the resectability of pancreatic cancer in selected patients.

Modified Appleby Procedure with Arterial Reconstruction for Locally Advanced Pancreatic Adenocarcinoma: A Literature Review and Report of Three Unusual Cases

BACKGROUND

Pancreatic body and tail ductal adenocarcinomas are often diagnosed with local vascular invasion of the celiac axis (CA) and its various branches. With such involvement, these tumors have traditionally been considered unresectable. The modified Appleby procedure allows for margin negative resection of some such locally advanced tumors. This procedure involves distal pancreatectomy with en bloc splenectomy and CA resection and relies on the presence of collateral arterial circulation via an intact pancreaticoduodenal arcade and the gastroduodenal artery to maintain prograde hepatic arterial perfusion. When the resultant collateral circulation is inadequate to provide sufficient hepatic and gastric arterial inflow, arterial reconstruction (AR) is necessary to "supercharge" the inflow. Herein, we review all reported cases of AR with modified Appleby procedures that we have identified in the literature, and we report our experience of three recent cases with arterial reconstruction including two cases with arterial bypasses not requiring interposition grafting.

METHODS

Perioperative and oncologic outcomes from our Institutional Review Board-approved database of pancreatic resections at the Thomas Jefferson University were reviewed. Additionally, PubMed search for cases of distal or total pancreatectomy with celiac axis resection and concurrent AR was performed.

RESULTS

From the literature, 12 reports involving 28 patients were identified of distal and total pancreatectomy with AR after CA resection. The most common AR in the literature, performed in 12 patients, was a bypass from the aorta to the common hepatic artery (CHA) using a variety of interposition conduits. In our institutional experience, patient #1 had a primary side-to-end aorto-CHA bypass, patient #2 had a primary end-to-end bypass of the transected distal CHA to the left gastric artery in the setting a replaced left hepatic artery, and patient #3 required an aortic to proper hepatic artery bypass with saphenous vein graft and portal venous reconstruction. All patients recovered from their operations without ischemic complications, and they are currently 16, 15, and 13 months post-op, respectively.

CONCLUSIONS

The criteria for resectability in patients with locally advanced pancreatic body and tail neoplasms are expanding due to increasing experience with AR in the setting of the modified Appleby procedure. When performing AR, primary arterial re-anastomosis may be considered preferable to interposition grafting as it decreases the potential for the infectious and thrombotic complications associated with conduits and it reduces the number of vascular anastomoses from two to one. Consideration must also be given to normal variant anatomy of the hepatic circulation during operative planning as the origin of the left gastric artery is resected with the CA. The modified Appleby procedure with AR, when used in appropriately selected patients, offers the potential for safe, margin negative resection of locally advanced pancreatic body and tail tumors.

Right gastro-omental artery reconstruction after pancreaticoduodenectomy for subtotal esophagectomy and gastric pull-up

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Pancreaticoduodenectomy is a difficult and challenging operation, and a gastric tube is frequently used for reconstruction after subtotal esophagectomy for esophageal cancer.

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The right gastro-omental artery is important for supplying blood flow to the gastric tube.

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Surgeries for pancreatic head tumors become incredibly difficult in patients who have undergone esophageal reconstruction with a gastric tube.

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We describe successful arterial reconstruction using the middle colic artery in a patient who had undergone esophageal reconstruction with a gastric tube and whose right gastro-omental artery had been resected.

Introduction

There are no reports on vessel reconstruction of right gastro-omental artery deficits due to pancreatic tumor resection. Here, we describe successful arterial reconstruction using the middle colic artery in a patient who had undergone esophageal reconstruction with a gastric tube and whose right gastro-omental artery had been resected.

Presentation of case

A 70-year-old man underwent subtotal esophagectomy and reconstructive surgery with a retrosternal gastric tube for esophageal cancer. A follow-up computed tomography (CT) scan revealed a tumor on the pancreatic head that was adjacent to the right gastro-omental artery. Pancreaticoduodenectomy (PD) was subsequently performed. The gastro-omental artery was resected along with the tumor, creating a 7-cm deficit. The anastomosis was performed between the right branch of the middle colic artery and the distal end of the right gastro-omental artery. No complications that involved blood flow to the reconstructed esophagus were postoperatively observed. Four months after surgery, the blood flow to the gastric tube was confirmed by a contrast CT scan.

Discussion

We reconstructed the right gastro-omental artery using the middle colic artery, and not a vein graft, as that would have required vessel anastomosis at two locations. The middle colic artery branches on the posterior surface of the pancreas, which is located close to the right gastro-omental artery.

Conclusion

The middle colic artery provides sufficient blood supply to the pulled-up gastric tube. PD can be performed even in patients who have undergone esophageal reconstruction.

First jejunal artery, an alternative graft for right hepatic artery reconstruction

Common bile duct cancer invading right hepatic artery is sometimes diagnosed intraoperatively. Excision and safe reconstruction of the artery with suitable graft is essential. Arterial reconstruction with autologous saphenous vein graft is the preferred method practiced routinely. However the right hepatic artery reconstruction has also been carried out with several other vessels like gastroduodenal artery, right gastroepiploic artery or the splenic artery. We report a case of 63-year-old man presenting with history of progressive jaundice, pruritus and impaired appetite. Following various imaging modalities including computed tomography, endoscopic retrograde cholangiopancreatography, magnetic resonance cholangiopancreatography, intraductal ultrasound extrahepatic bile duct cancer was diagnosed; however, none of those detected vessel invasion. Intraoperatively, right hepatic artery invasion was revealed. Right hepatic artery was resected and reconstructed with a graft harvested from the first jejunal artery (JA). Postoperative outcome was satisfactory with a long-term graft patency. First JA can be a reliable graft option for right hepatic artery reconstruction.

Efficacy of revascularization for critical limb ischemia in patients with end-stage renal disease

OBJECTIVE

To evaluate the outcomes of surgical revascularization for critical limb ischemia in patients with end-stage renal disease (ESRD).

PATIENTS AND METHODS

From 2004 to 2010, 184 patients with 213 critically ischaemic limbs caused by arteriosclerosis were admitted to The University of Tokyo Hospital. The outcomes of primarily surgical revascularization-based treatments were retrospectively compared in patients with ESRD (ESRD group: 79 patients, 101 limbs) and without ESRD (non-ESRD group: 105 patients, 112 limbs) during the same period.

RESULTS

Arterial reconstruction was performed on 56 limbs in 46 patients in the ESRD group and 78 limbs in 73 patients in the non-ESRD group (55% vs. 70%; p = .03). Major amputation was performed in 6 of 48 limbs with patent grafts in the ESRD group because of uncontrolled infection or progression of necrosis. The limb salvage rate after arterial reconstruction was significantly lower in the ESRD group than in the non-ESRD group (p = .0019). The postoperative survival rate was lower in the ESRD group than in the non-ESRD group, although this difference was not significant (p = .052). Associated cardiovascular disease and systemic infection were the most frequent causes of death in the ESRD group. There was no significant difference in graft patency between the two groups after distal bypass surgery; however, the limb salvage rate was significantly lower in the ESRD group than in the non-ESRD group (p = .03).

CONCLUSIONS

Critical limb ischemia associated with ESRD has a poor prognosis. Infection control is particularly important for achievement of good treatment outcomes.

Penile vascular surgery for treating erectile dysfunction: Current role and future direction

Penile vascular surgery for treating erectile dysfunction (ED) is still regarded cautiously. Thus we reviewed relevant publications from the last decade, summarising evidence-based reports consistent with the pessimistic consensus and, by contrast, the optimistically viable options for vascular reconstruction for ED published after 2003. Recent studies support a revised model of the tunica albuginea of the corpora cavernosa as a bi-layered structure with a 360° complete inner circular layer and a 300° incomplete outer longitudinal coat. Additional studies show a more sophisticated venous drainage system than previously understood, and most significantly, that the emissary veins can be easily occluded by the shearing action elicited by the inner and outer layers of the tunica albuginea. Pascal's law has been shown to be a significant, if not the major, factor in erectile mechanics, with recent haemodynamic studies on fresh and defrosted human cadavers showing rigid erections despite the lack of endothelial activity. Reports on revascularisation surgery support its utility in treating arterial trauma in young males, and with localised arterial occlusive disease in the older man. Penile venous stripping surgery has been shown to be beneficial in correcting veno-occlusive dysfunction, with outstanding results. The traditional complications of irreversible penile numbness and deformity have been virtually eliminated, with the venous ligation technique superseding venous cautery. Penile vascular reconstructive surgery is viable if, and only if, the surgical handling is appropriate using a sound method. It should be a promising option in the near future.

Reconstruction of the hepatic artery with the middle colic artery is feasible in distal pancreatectomy with celiac axis resection: A case report

Despite the advance of diagnostic modalities, carcinoma in the body and tail of the pancreas are commonly presented at a late stage. With unresectable lesions, long-term survival is extremely rare, and surgery remains the only curative option for pancreatic cancer. An aggressive approach by applying extended distal pancreatectomy with the resection of the celiac axis may increase the resectability and analgesic effect but great care must be taken with the arterial blood supply to the liver and stomach. Sometimes, accidental injury to the pancreatoduodenal artery compromises collateral blood flow and leads to fatal complications. Therefore, knowledge of any alternative restoration of the compromised collateral flow before surgery is essential. The present case report shows a patient with a pancreatic body cancer in whom the splenic, celiac, and common hepatic arteries were involved with the tumor, which extended almost to the root of the gastroduodenal artery. We modified the procedure by reanastomosis between the proper hepatic artery and middle colic artery without vascular graft. The postoperative course was uneventful, and the patient was discharged on postoperative day 19. The patient was immediately free of epigastric and back pain.