Anastomotic stenting in a porcine aortoiliac graft model

The purpose of the study was to evaluate the feasibility of anastomotic stent application in a porcine aortoiliac graft model. In a total of 10 pigs, a polytetrafluoroethylene aortobi-iliac graft was implanted through a midline abdominal incision. The lower edge of the iliac vessel was graft-inverted about 1 mm to produce irregularities at the downstream anastomosis. After transverse graft incision, six stainless-steel stents, six poly-L-lactic acid (PLLA) stents and four PLLA stents with 10% polycaprolactone (PCL) were implanted at the iliac anastomotic site using a 6 mm balloon dilatation catheter. Four anastomotic sites were left untreated. After two weeks, the patency of graft limbs was evaluated by contrast-enhanced computed tomography (CT). Both metal and polymeric stent designs provided adequate flexibility to manoeuvre across the anastomotic site for expansion in the chosen position. After deployment, the stent-arterial wall contact was complete on a macroscopic view. On CT scan, all metal and PLLA-stented graft limbs were free of stenosis, whereas all PLLA/PCL stents were occluded. The non-stented graft limbs showed a stenosis of 50-70%. In summary, this model is feasible to assess preclinically the deployment and patency rate of an anastomotic stent and to test future stent developments.

Funnel technique for first-line endovascular treatment of an abdominal aortic aneurysm with an ectatic proximal neck

PURPOSE

To describe a novel endovascular technique for proximal stent-graft fixation in an abdominal aortic aneurysm (AAA) with an ectatic aortic neck.

CASE REPORT

An 84-year-old man with multiple comorbidities and an asymptomatic 7-cm infrarenal AAA with a 38-mm aortic neck diameter was treated with a 3-component Talent-LPS stent-graft system. After the left internal iliac artery was embolized with coils, a 34 x 16 x 170-mm Talent bifurcated stent-graft was placed in the lower part of the AAA. A 44-mm-diameter, 90-mm-long free-flow thoracic tube endograft (6-mm oversizing) was delivered to the proximal neck through the bifurcated device and deployed with at least 30 mm of overlap, leaving more than 40 mm extending into the infrarenal aorta to ensure expansion to its nominal diameter as well as an adequate seal. An iliac extension was deployed into the left external iliac artery, and 2 sequential iliac extensions were inserted from the bifurcated stent-graft limb to the right common iliac artery in a bell-bottom configuration. Serial computed tomographic angiograms at up to 18 months have documented the intact 3-component stent-graft, with no endoleak or migration and no increase in aneurysm sac diameter.

CONCLUSION

This case illustrates the feasibility of placing a straight thoracic endograft as a proximal extension of a bifurcated aortic endograft into a dilated proximal aortic neck. This endograft configuration appears secure and effective, with no type I endoleak or migration over a midterm follow-up.

Vitreous cryopreservation maintains the viscoelastic property of human vascular grafts

Assess the effects of cryopreservation (cryo) and vitrification (vitro) on the viscoelastic properties of blood vessels. Human external Iliac artery vessels were harvested from liver organ donors (n=8). In each case the vessel was segmented into 3 equal parts, which were randomly placed in one of 3 categories: Fresh (stored in 4 degrees C UW for 6 h), Cryo (Placed in 10% Dulbecco's modified Eagle medium (DMEM) and slowly frozen to -196 degrees C), or Vitro (Placed in 40% DMEM and rapidly cooled to -196 degrees C). A pulsatile flow circuit was used to perfuse arterial segments at physiological pulse pressure and flow. Intraluminal pressure was measured using a Millar Mikro-tip catheter transducer, and vessel wall motion was determined with duplex ultrasonography coupled with a novel echo-locked vessel wall tracking system. Diametrical compliance (DC), Petersons elastic modulus (Ep), and stiffness index (beta) were then calculated for each of the three groups over 3 mean pressure ranging from 40 to 80 mmHg. The change in the viscous component of arterial wall (lag phase angle, theta) was calculated from hysteresis plots. No significant changes were observed in the elastic properties of fresh and vitrified vessels (P>0.05 for each of DC, Ep, and beta). Similarly, variation in the wall viscosity between fresh and vitrified vessels appeared to be nonsignificant (theta=12.60+/-4.04 vs. 17.60+/-1.14, respectively). In contrast, statistical analysis of results obtained for cryopreserved vessels to the fresh vessels showed significant reduction in elastic parameter values. There was also a significant increase in the phase angle theta of the cryopreserved vessels (theta=24.30+/-6.32; P<0.001) compared with fresh vessel. Results suggest that vitrification maintains both elastic and viscous components of the mechanical properties of vascular grafts, which is positively correlated with their functional patency. In contrast, damage caused during cryopreservation significantly affects the overall tensile strength and elasticity of the vessel (i.e., Ep and beta), the dynamic properties (DC), and appears to significantly affect the viscous component of the vessel wall (theta), which is likely reduce the patency of the graft for transplantation purposes.

CASE REPORTS: Penile Girth Augmentation Using Flaps “Shaeer's Augmentation Phalloplasty”: A Case Report

INTRODUCTION

Current girth augmentation techniques rely either on liposuction/injection or on the use of dermal fat grafts. These procedures have serious disadvantages, including regression in gained size, deformities, irregular contour, and asymmetry. Ideally, the augmentation technique should ensure durability and symmetry. This case report describes the first application of a flap (superficial circumflex iliac artery island flap) in penile girth augmentation.

MATERIALS AND METHODS

The superficial circumflex iliac vessels were identified and the groin flap was elevated from lateral to medial, rotated toward the penis, and tunneled into a penopubic incision. It was wrapped around the penis short of the corpus spongiosum and insinuated under the glans.

RESULTS

Six months after surgery, the patient had an erect girth of 19.5 cm and a flaccid girth of 16.5 cm, compared with 11 cm and 7 cm, respectively, before surgery, thus maintaining the intraoperative girth gain. The outer surface felt smooth with no lobulation. The size of the glans was proportionate to the shaft's girth.

CONCLUSION

This case report shows that the application of flaps in penile girth augmentation may provide a reliable alternative to the currently applied techniques. Glans flaring promotes the aesthetic results and is applicable with other techniques of penile girth augmentation.

The use of a composite graft of iliac artery and inferior mesenteric vein in liver transplantation

Innovation may be required for satisfactory arterial reconstruction in liver transplantation, particularly when the vessels obtained from the donor are inadequate. We have used a composite graft of donor iliac artery and recipient inferior mesenteric vein (IMV) between the infrarenal aorta and donor hepatic artery. Postoperative liver function was satisfactory, with normal daily duplex ultrasound scans for the first 2 weeks. At 4 years follow up, graft function is normal, a duplex ultrasound scan shows normal arterial flow and no dilatation of the composite graft, and a magnetic resonance angiogram reveals no evidence of dilatation or thrombosis of the composite graft. This is one of the few reported cases in which a composite graft has been used to arterialize the allograft in liver transplantation. A composite graft of iliac artery and IMV provided a satisfactory outcome in this patient and may be a valuable addition to the arterial grafts available to the liver transplant surgeon.

Outcome of hepatic artery reconstruction in liver transplantation with an iliac arterial interposition graft

BACKGROUND

In case of anomal hepatic arterial inflow, it can be necessary to perform revascularization of the liver allograft by iliac arterial interposition graft.

METHODS

We analyzed retrospectively 613 liver transplants in a 16-yr period. The hepatic artery (HA) graft group (n = 101) consisted of patients with arterial inflow based on recipient infrarenal aorta using donor iliac artery graft tunneled through the transverse mesocolon. The control group (n = 512) consisted of patients who underwent liver transplantation with routine HA reconstruction.

RESULTS

Both groups are homogeneous and comparable. In case of retransplantation, arterial conduit with iliac graft was adopted more frequently instead of conventional arterial anastomosis (24.8% vs. 9%, p < 0.0001). The 1-, 3- and 5-yr overall survival was 85.41, 79.42, 76.57% in the control group and 76.21, 73.43, 73.43% in the HA graft group, respectively (p = ns). The 1-, 3- and 5-yr graft survival was better in the control group (81.51, 73.66, 69.22% vs. 71.17, 62.50, 53.42%) (p = 0.01). In case of retransplantation, the 1-, 3- and 5-yr overall (57.81, 53.95, 41.96% vs. 60, 51.95, 49.85%) and graft survival (57.52, 53.68, 41.75% vs. 56, 50.4, 40.3%) was similar in control and HA graft group, respectively (p = ns). Hepatic artery thrombosis (HAT) rate is 21.8% vs. 8.6% (p < 0.0001) in HA graft group and control group, respectively. The only factor independently predictive of early HAT resulted arterial conduit (p = 0.001, OR = 3.13, 95% CI: 1.57-6.21). Retransplant procedure, donor age and arterial iliac conduit were found to be a significant risk factors for late HAT, at univariate analysis. At multivariate analysis, donor age >50 yr old resulted the only factor independently associated with late HAT (p < 0.0001, OR = 1.05, 95% CI: 1.02-1.07).

CONCLUSION

Iliac arterial interpositional graft is an alternative solution for arterial revascularization of liver allograft in case of retransplantation when the use of HA is not possible. In case of primary transplantation, is better not to perform arterial conduit if it is possible, for poor graft survival and high incidence of early HAT, especially in case of liver donor aged over 50 yr.

[Effects of platelet derived growth factor antisense oligodeoxynucleotides and tissue-type plasminogen activator gene transfection on inhibition of intimal proliferation]

OBJECTIVE

To observe the effects of co-transfection of platelet derived growth factor antisense oligodeoxynucleotides (PDGF-AODN) and tissue-type plasminogen activator (tPA) gene on inhibition of intimal proliferation of auto-transplantion artery.

METHODS

One hundred male New Zealand rabbits were randomly divided into four groups (25 in each): Group A (control group), Group B (PDGF-AODN transfection group), Group C (tPA gene transfection group) and Group D (PDGF-AODN and tPA co-transfection group). The left and right external iliac arteries were transplanted reciprocally. The transplanted arteries were respectively soaked in PDGF-AODN, pBudCE4.1/tPA and PDGF-AODN plus pBudCE4.1/tPA solution about 15 minute before transplantation. The rabbits were sacrificed at 3d, 1w, 2w, 4w and 8w after operation. The specimens were harvested for pathologic examination, electron microscopy, chromogenic substrate test, 3H-TdR incorporation test and immunohistochemical staining.

RESULT

The scan electron microscopy showed that there were a few thrombocytes on vas-wall of Group C and D without thrombus, whereas there were abundant thrombocytes and thrombus forming on vas-wall of Group A and B. The intimal area, stenosis ratio of transplanted artery, 3H-TdR incorporation,the number of PDGF positive cell in Group D were significantly less than those in Group A (P<0.01),Group B and Group C (both P<0.05). The activity of tPA gene products in transplanted vas-wall of Group D was significantly higher than that of Group A (P<0.01).

CONCLUSION

Local co-transfection of PDGF-AODN and tPA gene can effectively inhibit the proliferation of vascular smooth muscle cells, hyperplasia of intima and restenosis of transplanted artery.

Cryopreserved iliac artery is indispensable interposition graft material for middle hepatic vein reconstruction of right liver grafts

Cryopreserved iliac vein grafts (IVGs) have often been used for reconstruction of middle hepatic vein (MHV) branches in right liver grafts, but their storage pool has often been exhausted in our institution due to the low incidence of deceased donor organ procurement. To overcome this shortage of IVG, we started to use cryopreserved iliac artery graft (IAG). During September and October 2004, we carried out 41 cases of adult living donor liver transplantation, including 29 right lobe grafts with MHV reconstruction. Interposition vessel grafts were autologous vein (n = 6), IVG (n = 13), and IAG (n = 10). IAG was used in 3 (21%) of 13 cases during the first month. For the next month, it was more frequently used (7 [44%] of 16) because handling of cryopreserved IAG was not difficult and its outcome was favorable. On follow-up with computed tomography for 3 months, outflow disturbance occurred in 1 (17%) of 6 autologous vein cases, in 2 (15%) of 13 IVG cases, and in 1 (10%) of 10 IAG cases. Two-month patency rate of IAG was not lower than that of IVG. In conclusion, we feel that cryopreserved IAG can be used as an interposition vessel graft for MHV reconstruction of right liver graft when cryopreserved IVG is not available.

Patency and structural changes in cryopreserved arterial grafts used as vessel substitutes in the rat

OBJECTIVE

To evaluate the patency and structural changes that occur in the short- and mid-term when cryopreserved syngenic arterial grafts are implanted in an experimental animal model.

MATERIAL AND METHODS

Segments of iliac artery from the Spraque-Dawley rat were cryopreserved in a biological freezer according a controlled, computerized freezing protocol whereby the specimens are cooled at a rate of 1 degrees C/min. After storage at -145 degrees C in liquid N2 vapor for 30 days, the cryografts were slowly thawed. These vessels were grafted to the common iliac artery in syngenic animals. The following study groups were established: group I (GI), non-implanted cryografts; group II (GII), autografts; and group III (GIII), cryoisografts. The control group (CG) was comprised of fresh iliac arteries. The animals were sacrificed 14, 30, or 90 days post-surgery. At each of these follow-up times, graft specimens were morphologically evaluated by light and scanning and transmission electron microscopy and immunolabeling of endothelial cells (vWf). Cell damage attributed to the cryopreservation or grafting process was also determined.

RESULTS

At the time of sacrifice, graft patency was 100% for the autografts, while 26.6% of the cryoisografts showed fully occlusive thrombosis. Among other complications, two pseudoaneurysms were detected. After cryopreservation, the grafts (GI) showed patches of endothelial denudation and good cellularity of the medial layer. The intimal hyperplasia observed in autografts implanted for 14 days (GII) was significantly delayed until day 30 when the graft was cryopreserved (GIII). Cryoisografts showed general thinning of the arterial wall and degeneration accompanied by medial layer cell loss. These grafts showed most cell damage at 90 days post-implant. Expression of the vWf in all specimens showing intimal hyperplasia was confined to the outermost graft layer.

CONCLUSIONS

Cryopreservation modified the reparative response of the grafts. Owing to faster degeneration of the medial layer and a delay in the appearance of intimal hyperplasia, arterial wall thickness was reduced relative to that of the non-cryopreserved autografts. This thinning, at least in the short-term (90 days), does not seem to give rise to aneurysms owing to the generation of a neointima that stabilizes the vessel wall.

Tissue Engineering of Recellularized Small-Diameter Vascular Grafts

A tissue-engineered small-diameter arterial graft would be of benefit to patients requiring vascular reconstructive procedures. Our objective was to produce a tissue-engineered vascular graft with a high patency rate that could withstand arterial pressures. Rat arteries were acellularized with a series of detergent solutions, recellularized by incubation with a primary culture of endothelial cells, and implanted as interposition grafts in the common femoral artery. Acellular grafts that had not been recellularized were implanted in a separate group of control animals. No systemic anticoagulants were administered. Grafts were explanted at 4 weeks for definitive patency evaluation and histologic examination; 89% of the recellularized grafts and 29% of the control grafts remained patent. Elastin staining demonstrated the preservation of elastic fibers within the media of the acellular grafts before implantation. Immunohistochemical staining of explanted grafts demonstrated a complete layer of endothelial cells on the lumenal surface in grafts that remained patent. Smooth muscle cells were observed to have repopulated the vessel walls. The mechanical properties of the matrix were comparable to native vessels. Such a strategy may present an alternative to autologous harvest of small vessels for use in vascular bypass procedures.

Arterial reconstruction with donor iliac vessels during pancreas transplantation: an intraoperative approach to arterial injury or inadequate flow

BACKGROUND

Outcome of pancreas transplantation (PTX) has improved because of use of novel immunosuppression and advances in surgical technique. It is not uncommon for severe atherosclerosis in patients with type 1 insulin-dependent diabetes mellitus or the presence of a previously transplanted organ to limit the options for vascular anastomosis. Herein we report the novel application of donor iliac arterial interposition grafts for arterial reconstruction in patients with severe iliac artery arteriosclerosis, and/or previous transplant who develop an arterial injury or stenosis during surgery.

METHODS

In five patients undergoing PTX, the external iliac artery was severely atherosclerotic and/or occupied by a previous vascular anastomosis. In four of the five patients, an arterial intimal dissection became apparent. The external iliac artery was excised and reconstructed with donor iliac artery interposition graft (end-to-end anastomosis). Pancreas or kidney was engrafted onto this arterial interposition graft (end-to-side anastomosis).

RESULTS

There was no operative morbidity related to this surgical approach. All grafts functioned well after transplantation. Distal lower extremities have no evidence of vascular insufficiency with mean follow-up of 26 months (7-45 months).

CONCLUSION

This surgical technique is an acceptable option during PTX for the patient with severe iliac artery arteriosclerosis with intraoperative intimal dissection or stenosis, or perhaps those with challenging arterial access.

[The study on platelet-derived growth factor and proliferating cell nuclear antigen antisense oligodeoxynucleotides together inhibiting the stenosis of transplanted vascular]

OBJECTIVE

To study the effect of platelet-derived growth factor (PDGF) and proliferating cell nuclear antigen (PCNA) antisense oligodeoxynucleotides (AODN) together on inhibiting the proliferation of the stenosis of transplanted vascular.

METHODS

The left and right external iliac arteries (length 1.0 cm) of rabbits were transplanted reciprocally. The transplanted vascular were respectively soaked in liposomes, PDGF-AODN, PCNA-AODN and PDGF-AODN adding PCNA-AODN solution about 20 minute, the vascular anastomotic were sutured by 8/0 suture of soaked in AODN solution. Four weeks later, the specimens were harvested for microscopy. The pathological morphology of transplanted vascular were observed under microscope (HE). The intimal thickness and area, stenosis ratio(%) of transplanted vascular were calculate and analysed statistically among group by computer system. The number of positive cells of PDGF's mRNA in transplanted vascular wall were counted with in situ hybridization histo-cytochemistry and the number of positive cells of PCNA's protein in transplanted vascular wall were counted by S-P immunochemistry.

RESULTS

The intimal thickness and area, stenosis ratio of transplanted vascular, the number of PDGF and PCNA positive cell in PDGF-AODN adding PCNA-AODN group were significantly lower than those in other group (P < 0.01), and that were lower evidently than PDGF-AODN group and PCNA-AODN group.

CONCLUSION

PDGF and PCNA antisense oligodeoxynucleotides together could significantly inhibit the proliferation of vascular smooth muscle cell and stenosis of transplanted vascular.

Transmission of rabies virus from an organ donor to four transplant recipients

BACKGROUND

In 2004, four recipients of kidneys, a liver, and an arterial segment from a common organ donor died of encephalitis of an unknown cause.

METHODS

We reviewed the medical records of the organ donor and the recipients. Blood, cerebrospinal fluid, and tissues from the recipients were tested with a variety of assays and pathological stains for numerous causes of encephalitis. Samples from the recipients were also inoculated into mice.

RESULTS

The organ donor had been healthy before having a subarachnoid hemorrhage that led to his death. Encephalitis developed in all four recipients within 30 days after transplantation and was accompanied by rapid neurologic deterioration characterized by agitated delirium, seizures, respiratory failure, and coma. They died an average of 13 days after the onset of neurologic symptoms. Mice inoculated with samples from the affected patients became ill seven to eight days later, and electron microscopy of central nervous system (CNS) tissue demonstrated rhabdovirus particles. Rabies-specific immunohistochemical and direct fluorescence antibody staining demonstrated rabies virus in multiple tissues from all recipients. Cytoplasmic inclusions consistent with Negri bodies were seen in CNS tissue from all recipients. Antibodies against rabies virus were present in three of the four recipients and the donor. The donor had told others of being bitten by a bat.

CONCLUSIONS

This report documenting the transmission of rabies virus from an organ donor to multiple recipients underscores the challenges of preventing and detecting transmission of unusual pathogens through transplantation.

Transcatheter Embolization of Internal Pudendal Artery Pseudoaneurysm Following Traumatic Urethral Catheterization

Urethral catheterization is a routine procedure. We report an unusual complication due to a traumatic urethral catheterization. The resulting pseudoaneurysm of the bulbar artery required selective embolization of the internal pudendal artery.

Deep circumflex iliac artery (DCIA) free flap without DCIA: report of a unique case

The iliac crest free flap is a reliable source of cancellous bone, muscle, and skin. The vascularization of this flap arises from the deep circumflex iliac artery (DCIA) which allegedly is always present. The authors report a unique case of successful microvascular transplantation of an iliac crest osteomyocutaneous free flap in a patient in whom the DCIA and DCIV were absent.

Update: investigation of rabies infections in organ donor and transplant recipients--Alabama, Arkansas, Oklahoma, and Texas, 2004

On July 1, 2004, CDC reported laboratory confirmation of rabies as the cause of encephalitis in an organ donor and three organ recipients at Baylor University Medical Center (BUMC) in Dallas, Texas. Hospital and public health officials in Alabama, Arkansas, Oklahoma, and Texas initiated public health investigations to identify donor and recipient contacts, assess exposure risks, and provide rabies postexposure prophylaxis (PEP). As of July 9, PEP had been initiated in approximately 174 (19%) of 916 persons who had been assessed for exposures to the organ recipients or the donor. As a result of its public health investigation, the Arkansas Department of Health determined that the donor had reported being bitten by a bat (Frank Wilson, M.D., Arkansas Department of Health, personal communication, 2004).

Thoracovisceral segment aneurysm repair after previous infrarenal abdominal aortic aneurysm surgery

OBJECTIVE

Repair of thoracovisceral aortic aneurysms (TVAA) after previous open repair of an infrarenal abdominal aortic aneurysm (AAA) poses significant challenges. We sought to better characterize such recurrent aneurysms and to evaluate their operative outcome.

METHODS

We reviewed the records and radiographs of 49 patients who underwent repair of TVAAs between 1988 and 2002 after previous repair of an AAA. Visceral artery reconstructions were completed with combinations of beveled anastomoses, inclusion patches, and side arm grafts. In 14 patients visceral endarterectomy was required to treat associated occlusive disease. Sixteen patients had cerebrospinal fluid drainage, and 10 patients had distal perfusion during cross-clamping.

RESULTS

Patient mean age was 72 years, and 80% were men. Fifty-one percent of patients had symptomatic disease, and average TVAA diameter was 6.2 cm. Mean time between AAA and TVAA repair was 77 months. Twenty-six percent of aneurysms were restricted to the lower visceral aortic segment, 35% extended to the diaphragm, another 35% extended to the distal or middle thoracic aorta, and 4% involved the entire remaining visceral and thoracic aorta. The 30-day operative mortality rate was 4.1% in patients with nonruptured aneurysms and 50% in patients with ruptured aneurysms, for an overall mortality rate of 8.2%. Fifteen patients (30.6%) had major morbidity, including paresis in two patients and dialysis-dependent renal failure in five patients. At late follow-up, three patients required further aortic operations to treat additional aneurysms, and four patients had fatal aortic ruptures. Two-year and 5-year cumulative survival rates were 61% (+/-7.5%) and 37% (+/-7.8%), respectively. At univariate analysis, operative blood loss was the sole significant predictor of major morbidity (P <.023), and rupture (P <.030, P <.0001) and aneurysm extent (P <.0007, P <.0001) correlated with both operative death and long-term survival. Only aneurysm extent (P <.010, relative risk 37.3) remained a significant predictor of long-term survival at multivariate analysis.

CONCLUSION

Elective repair of TVAAs after previous AAA repair can be performed with an acceptable level of operative mortality, though with considerable operative morbidity. Limited long-term survival mandates careful patient selection, and the high mortality associated with ruptured TVAA underscores the need for post-AAA surveillance.

Extended donor iliac arterial patch for vascular reconstruction during pancreas transplantation

Iliac arteries in allograft pancreas recipients may be compromised by the patient's underlying disease or previous surgical intervention. We describe a previously unreported arterial reconstruction using an extended segmental common/external iliac artery patch with anastomosis of the pancreatic Y-graft to the patch internal iliac artery, and review the options for arterial reconstruction reported by others. This technique may find application in both pancreas and kidney transplantation to salvage a damaged or diseased iliac artery.

Pediatric blunt trauma resulting in major arterial injuries

Ten children, aged 4 to 14 years, sustaining blunt arterial trauma from motor vehicle collisions (6), bicycle accidents (2), and falls (2) were identified over a 10-year period. The arteries injured included the common iliac (3), abdominal aorta (2), carotid (2), brachial (2), and the subclavian, renal, and femoral artery (1 each). One patient had three arterial injuries. Six patients had associated injuries including a pelvic and lumbar spine fracture, Horner's syndrome, liver laceration, skull fracture, open humerus fracture, small bowel serosal tear, and a brachial plexus injury. Definitive diagnosis was made using arteriography (6), computed tomography (CT) scan (2), and physical examination (2). The types of arterial injuries found included incomplete transection, complete transection with pseudo-aneurysm formation, traumatic arteriovenous (AV) fistulas, complete occlusion, and dissection. Repair was accomplished by hypogastric artery interposition or bypass grafting, synthetic grafting with polytetrafluoroethylene (PTFE), reverse saphenous vein grafting, or primary repair, depending on the circumstances. An AV fistula between the carotid artery and cavernous sinus was embolized. All grafts remained patent with exception of the aorto-renal bypass graft at follow-up ranging from 1 month to 3 years. The principles for repairing vascular injuries in children are slightly different than those in adults. Every effort should be made to use autogenous tissue such as the hypogastric artery or saphenous vein for repair if possible. If not, PTFE grafts can be used, although the long-term patency of these grafts in growing children is not known.

Arterial conduits for hepatic artery revascularisation in adult liver transplantation

Arterial complications after orthotopic liver transplantation (OLT), including hepatic artery thrombosis (HAT), are important causes of early graft failure. The use of an arterial conduit is an accepted alternative to the utilisation of native recipient hepatic artery for specific indications. This study aims to determine the efficacy of arterial conduits and the outcome in OLT. We retrospectively reviewed 1,575 cadaveric adult OLTs and identified those in which an arterial conduit was used for hepatic revascularisation. Data on the primary disease, indication for using arterial conduit, type of vascular graft, operative technique and outcome were obtained. Thirty-six (2.3%) patients underwent OLT in which arterial conduits were used for hepatic artery (HA) revascularisation. Six of these were performed on the primary transplant, while the rest (n=30) were performed in patients undergoing re-transplantation, including six who had developed hepatic artery aneurysms. The incidence of arterial conduits was 0.4% (6/1,426 cases) in all primary OLTs and 20.1% (30/149 cases) in all re-transplants. Twenty-nine procedures utilised iliac artery grafts from the same donor as the liver, six used iliac artery grafts from a different donor, and a single patient underwent a polytetrafluoroethylene (PTFE) graft. Two techniques were used: infra-renal aorto-hepatic artery conduit and interposition between the donor and recipient native HAs, or branches of the HAs. The 30-day mortality rate for operations using an arterial conduit was 30.6%. Three conduits thrombosed at 9, 25 and 155 months, respectively, but one liver graft survived without re-transplantation. The arterial conduits had 1- and 5-year patency rates of 88.5% and 80.8%. The 1- and 5-year patient survival rates were 66.7% and 44%. We can thus conclude that an arterial conduit is a viable alternative option for hepatic revascularisation in both primary and re-transplantation. Despite a lower patency rate than that of native HA in the primary OLT group, the outcomes of arterial conduit patency and patient survival rates are both acceptable at 1 and 5 years, especially in the much larger re-OLT group.

Assessment of connective tissue fibres in walls of allogenic arterial grafts preserved by the method of cold ischemia--a preliminary report

The aim of the study was to evaluate microscopic changes in the wall structures of allogenic arterial grafts, preserved by the method of cold ischemia in relation to the storage period and to test the possibility of the storage period prolongation by allograft freezing at -70 degrees C. The middle layer ultrastructure is well preserved till 30 days from allograft harvesting, however, allograft freezing results in total destruction of elastic and collagen fibres in the arterial wall. An application of allogenic arterial grafts, preserved by the method of cold ischemia till 30 days from their harvesting, seems an efficient therapeutic method in the treatment of patients with synthetic vascular graft infection. Further prolongation of the storage period at -70 degrees C made the allograft useless for implantation.

A comparison of the long-term morbidity following deep circumflex iliac and fibula free flaps for reconstruction following head and neck cancer

Composite free tissue transfer has an established role in head and neck oncology for the reconstruction of the bony defect following tumor ablation, and while donor-site morbidity is variably reported, there is little consensus on the most favorable donor site. The fibula and deep circumflex iliac artery have distinct advantages in terms of the volume and length of bone in mandibular reconstruction. Few studies have compared their donor-site morbidity. The aim of this study was to compare the fibula and deep circumflex iliac artery flaps using a review of the case notes and cross-sectional review of patients attending a research clinic for validated orthopedic examination and completion of health-related quality-of-life questionnaires. Between February of 1993 and May of 2001, 44 fibula free flaps and 73 deep circumflex iliac artery free flaps were performed. Ninety-nine case notes and 36 patients were available for review of donor-site morbidity. Sixteen patients with fibula flaps and 20 patients with deep circumflex iliac artery flaps took part in the clinical examination component of the study, which was composed of a clinical examination by an orthopedic surgeon using the American Orthopedic Foot and Ankle Society ankle scoring system and the Harris hip scoring system, and two patient-completed questionnaires, the University of Washington Questionnaire and the Hospital Anxiety and Depression Scale. Subjective and objective markers of morbidity related to both flaps were similar in most parameters. However, fibula flaps were associated with more problems with donor-site healing, reduced power, and sensation. Poor orthopedic scores for both flaps were associated with notably poor scores on the University of Washington Questionnaire and the Hospital Anxiety and Depression Scale. The study would suggest that both deep circumflex iliac artery and fibula donor sites result in an acceptable and comparable morbidity for most patients, but in cases in which significant donor-site morbidity is encountered, health-related quality of life is significantly compromised.

Experimental vascular graft for liver transplantation

Hepatic artery thrombosis is a major cause of graft failure in liver transplantation. Use of donor interponates are common, but results are controversial because of necrosis or thrombosis after rejection. Reperfusion injury, hypoxia and free radical production determinate the survival. The aim of the study was to create an 'ideal' arterial interponate. Autologous, tubular graft lined with mesothelial cells, prepared from the posterior rectus fascia sheath, was used for iliac artery replacement in eight mongrel dogs for six months under immunosuppression. Patency rate was followed by Doppler ultrasound. Eight grafts remained patent and another two are patent after one year. The patency rate was good (median Doppler flow: 370 cm/sec) and there was no necrosis, thrombosis or aneurysmatic formation. The grafts showed viable morphology with neoangiogenesis, appearance of elastin, smooth muscle and endothelial cells. Electron microscopy showed intact mitochondrial structures without signs of hypoxia. Tissue oxygenation was good in all cases with normal (< 30 ng/ml) myeloperoxidase production. In conclusion, this autologous graft presents good long-term patency rate. Viability, arterialisation and low thrombogenicity are prognostic factors indicating usability of the graft in the clinical practice without the risk of rejection. Further investigations such as cell cultures and standardisation are necessary.