Two-flap technique with interpositional dermofat graft for anterior oronasal fistula closure in patients with cleft: A case series

BACKGROUND

Oronasal fistula at the anterior hard palate is one of the common sequelae after cleft surgery, and the leakage negatively affects the patient's quality of life. Although several surgical techniques have been proposed for reconstruction, it remains challenging because of the scarred regional tissue with a high rate of fistula recurrence. In this study, we present the anterior oronasal fistula repair using a two-flap technique with an interpositional dermofat graft (DFG).

METHODS

A retrospective review of anterior oronasal fistula repair performed by the senior author between April 2018 and August 2022 at the Craniofacial Center was conducted. Patients who underwent a fistula repair using the technique were further identified and investigated.

RESULTS

Thirty-four operations were performed using the technique, and 31 fistulas were completely closed, with a success rate of 91.2%. The fistula symptom improved but persisted postoperatively in 3 patients, of whom 2 patients underwent a second fistula repair using the same procedure, resulting in successful closure. Fistula recurrence was significantly correlated with fistula size (p = 0.04). The DFG was simultaneously utilized for nasal dorsum and/or vermillion reconstruction in 28 cases.

CONCLUSION

The two-flap technique enabled tension-free approximation, and the interpositional DFG facilitated watertight closure of the fistula, resulting in a high success rate of anterior oronasal fistula repair. The fistula closure could be combined with other revisional procedures for cleft-related deformities, where the DFG was simultaneously utilized.

Superficial temporal artery interposition bypass for the treatment of complex intracranial aneurysms: Flexible and creative options for flow preservation bypass

PURPOSE

Flow-preservation bypass is a treatment option for complex intracranial aneurysms (IAs) that cannot be managed with microsurgical clipping or endovascular treatment. Various bypass methods are available, including interposition grafts such as the radial artery or saphenous vein. Size discrepancy, invasiveness, and procedure complexity must be considered when using interposition grafts. We describe our experience of treating complex IAs using a superficial temporal artery (STA) interposition bypass.

METHODS

We retrospectively reviewed the medical records and operative videos of all patients who were treated for complex IAs at our center from January 2009 to December 2021 using cerebral revascularization. Clinical, radiological, and surgical findings of the cases that underwent STA interposition bypass were investigated.

RESULTS

Seventy-six bypass procedures were performed of which seven (9.2%) complex IAs were managed using STA interposition bypass. Of these 5 cases were of anterior cerebral artery, 1 of middle cerebral artery, and 1 of posterior inferior cerebellar artery aneurysm. There were no postoperative ischemic complications. Revision surgery for postoperative pseudomeningocele was performed in one case. The long-term bypass patency rate was 85.7% (6 out of 7) and good long-term aneurysm control was achieved in all cases, with a mean follow-up of 64 months.

CONCLUSIONS

When treating complex IAs, creative revascularization strategies are needed in selective cases for favorable outcomes. STA interposition graft bypass which can reduce the size discrepancy between the donor and recipient may be a less invasive, flexible, and practical option for treating complex IAs.

Surgical treatment of chronic achilles tendon rupture: An anatomical consideration of various autograft options

Background

Acute Achilles tendon rupture is a common injury and when missed leads to the development of a chronic Achilles tendon rupture. Studies suggest surgical treatment (either repair or reconstruction) for most patients with a chronic Achilles rupture due to the functional deficit caused by the lack of an intact Achilles tendon. Numerous autograft options such as the flexor hallucis longus, hamstrings, peroneal and quadriceps tendon have been used to reconstruct the Achilles tendon, either as a tendon transfer or as an interposition graft. The choice of autograft used usually depends on the size of the defect left after debridement of the Achilles tendon edges, but is often dictated by surgeon preference and tissue availability. Currently, there is no consensus as to the best autograft option.

Aims and methodology

The aim of this study was to evaluate the various autograft options used to reconstruct the Achilles tendon, and the advantages and disadvantages of using each tendon, focussing specifically on the harvesting technique, anatomical and biomechanical properties. This was done by reviewing the current published literature, supplemented by carrying out anatomical dissection in the cadaveric lab.

Results

The flexor hallucis longus is synergistically related to the Achilles tendon and biomechanically strong, however harvesting can result in weakness in big toe flexion. The peroneus brevis whilst being biomechanically strong is a much shorter tendon compared to the other autograft options. Similarly, the quadriceps tendon is also a strong tendon option, but may not be appropriate for larger chronic Achilles tendon rupture gaps. The semitendinosus tendon can be tripled/quadrupled to resemble the Achilles tendon, but is associated with higher risks of patient morbidity when harvesting the tendon.

Conclusion

Treatment of chronic Achilles tendon ruptures remains a challenge. Each autograft option has its own unique advantages and disadvantages which should be considered on a case-specific basis. Further work is required to analyse the biomechanical properties of the autograft options to determine if one option is superior.

Portal vein reconstruction in pediatric liver transplantation using end-to-side jump graft: A case report

Attenuated portal vein (PV) flow is challenging in pediatric liver transplantation (LT) because it is unsuitable for classic end-to-end jump graft reconstruction from a small superior mesenteric vein (SMV). We thus introduce a novel technique of an end-to-side jump graft from SMV during pediatric LT using an adult partial liver graft. We successfully performed two cases of end-to-side retropancreatic jump graft using an iliac vein graft for PV reconstruction. One patient was a 2-year-old boy with hepatoblastoma and a Yerdel grade 3 PV thrombosis who underwent split LT. Another patient was an 8-month-old girl who had biliary atresia and PV hypoplasia with stenosis on the confluence level of the SMV; she underwent retransplantation because of graft failure related to PV thrombosis. After native PV was resected at the SMV confluence level, an end-to-side reconstruction was done from the proximal SMV to an interposition iliac vein. The interposition vein graft through posterior to the pancreas was obliquely anastomosed to the graft PV. There was no PV related complication during the follow-up period. Using a jump vascular graft in an end-to-side manner to connect the small native SMV and the large graft PV is a feasible treatment option in pediatric recipients with inadequate portal flow due to thrombosis or hypoplasia of the PV.

Rotator cuff repair with an interposition polypropylene mesh: A biomechanical ovine study

BACKGROUND

Chronic large to massive rotator cuff tears are difficult to treat and re-tears are common even after surgical repair. We propose using a synthetic polypropylene mesh to increase the tensile strength of rotator cuff repairs. We hypothesize that using a polypropylene mesh to bridge the repair of large rotator cuff tears will increase the ultimate failure load of the repair.

AIM

To investigate the mechanical properties of rotator cuff tears repaired with a polypropylene interposition graft in an ovine ex-vivo model.

METHODS

A 20 mm length of infraspinatus tendon was resected from fifteen fresh sheep shoulders to simulate a large tear. We used a polypropylene mesh as an interposition graft between the ends of the tendon for repair. In seven specimens, the mesh was secured to remnant tendon by continuous stitching while mattress stitches were used for eight specimens. Five specimens with an intact tendon were tested. The specimens underwent cyclic loading to determine the ultimate failure load and gap formation.

RESULTS

The mean gap formation after 3000 cycles was 1.67 mm in the continuous group, and 4.16 mm in the mattress group (P = 0.001). The mean ultimate failure load was significantly higher at 549.2 N in the continuous group, 426.4 N in the mattress group and 370 N in the intact group (P = 0.003).

CONCLUSION

The use of a polypropylene mesh is biomechanically suitable as an interposition graft for large irreparable rotator cuff tears.

Acute limb ischemia secondary to external iliac and common femoral artery dissection in a body builder

Spontaneous external iliac artery dissection in highly trained athletes is becoming more recognized, but the reason as to why they are occurring remains a mystery. We present a patient with acute limb ischemia secondary to arterial dissection after strenuous exercise. Imaging showed complete occlusion of the distal common iliac artery, and the patient underwent successful revascularization of the right lower extremity using a hybrid approach.

Arthroscopic Management of Thumb Carpometacarpal Joint Arthritis and Pathology

Basilar thumb arthritis is a debilitating condition characterized by pain, reduced joint stability, and reduced capacity for daily activities. Various arthroscopic approaches have been described based on patient factors, as well as radiographic and arthroscopic staging criteria. Here we provide an overview of arthroscopic management of basilar thumb arthritis, including patient evaluation, surgical techniques, outcomes, and new developments. We describe our preferred approach for Eaton stage I-III disease, consisting of arthroscopic hemitrapeziectomy with suture button suspensionplasty. This technique is safe, reliable, and allows for early range of motion and quicker recovery while minimizing scarring and reducing the risk of nerve injury.

Treatment of massive irreparable rotator cuff tears using dermal allograft bridging reconstruction

AIMS

Various options are available for treating massive irreparable rotator cuff tears, but all have their own limitations and no gold standard currently exists. Our aim was to report on outcomes of bridging repair with a dermal allograft for symptomatic massive irreparable rotator cuff tears where primary or partial repair was not possible.

PATIENTS AND METHODS

We prospectively reviewed 22 patients who underwent an open interposition bridging repair with an allograft (GraftJacket) sutured medially to the residual rotator cuff stump and laterally to the footprint with suture anchors. Mean age at time of surgery was 59 years (range 53-66 years). The Oxford Shoulder Score, pain visual analogue scale and range of motion were compared pre-operatively and at mean follow up of 2.8 years. All patients had a postoperative MRI scan.

RESULTS

There was a significant improvement in mean Oxford Shoulder Score from a pre-operative score of 14.2-34.3 points (p < 0.01) at final follow up. Pain VAS score improved from 6.6 points to 2.8 points (p < 0.05). Significant improvements in range of motion were also seen. Postoperative MRI scans showed a retear in 8 patients (36%), but the retear size was smaller and an improvement in outcomes maintained at final follow up.

CONCLUSION

Open dermal allograft bridging repair for massive irreparable rotator cuff tears can lead to satisfactory outcomes and delay the need for a reverse shoulder arthroplasty.

Living donor liver transplantation in a pediatric patient with congenital absence of the portal vein

Congenital absence of the portal vein (CAPV) is a rare venous malformation in which mesenteric venous blood drains directly into the systemic circulation. We report a case of pediatric living donor liver transplantation (LDLT) for CAPV combined with focal nodular hyperplasia (FNH) and hepatocellular adenoma. A 9-year-old girl who had been diagnosed with multiple FNH had CAPV. Her blood ammonia level was raised to 137 μg/dL. However, she did not complain of any symptoms. To treat CAPV and FNH, we decided to perform LDLT. The graft was a left liver graft from 39-year-old mother of the patient. Recipient hepatectomy was performed according to standard procedures of pediatric LDLT. Portal vein reconstruction was performed using interposition of an iliac vein homograft conduit to the superior mesenteric vein-splenic vein confluence. The CAPV-associated congenital splenorenal shunt was securely ligated. The pathology report of the explant liver showed a 2 cm-sized hepatocellular adenoma and multiple FNH lesions measuring up to 7.1 cm. The patient recovered uneventfully from the LDLT operation. The reconstructed portal vein was maintained well without any hemodynamic abnormalities. In conclusion, as CAPV patients can have various vascular anomalies, combined vascular anomalies should be thoroughly assessed before and during liver transplantation operation. The most effective reconstruction techniques should be used to achieve satisfactory results following liver transplantation.

Interposition Grafting of the Facial Nerve After Resection of a Large Facial Nerve Schwannoma: 2-Dimensional Operative Video

Facial nerve schwannomas can develop at any portion of the facial nerve.1 When arising from the mastoid portion of the facial nerve, the tumor will progressively erode the mastoid, giving the schwannoma an aggressive radiological appearance.1,2 The facial nerve is frequently already paralyzed, or no fascicles can be saved during resection. In these cases, end-to-end interposition grafting is the best option for facial reanimation.1,3-5 The healthy proximal and distal facial nerves are prepared prior to grafting. The great auricular nerve is readily available near the surgical site and represents an excellent graft donor with minimal associated morbidity.4,6 We demonstrate this technique through a case of a 48-yr-old male who presented with a complete right-sided facial nerve palsy due to a large facial schwannoma that invaded the mastoid and extended to the hypoglossal canal, causing hypoglossal nerve paralysis, and petrous carotid canal. His 4-yr follow-up showed no recurrent tumor with restored facial nerve function palsy to a House-Brackman grade III, and full recovery of his hypoglossal nerve function. The patient consented to the surgery and the publication of his image.

Superficial Temporal Artery Extended Interposition Graft to Anterior Cerebral Artery Bypass for the Treatment of a Large Fusiform Distal Anterior Cerebral Artery Aneurysm: 2-Dimensional Operative Video

Fusiform aneurysms of the distal anterior cerebral artery (DACA) are infrequent. Clip reconstruction and sequential progressive clipping have been described in the management of giant thrombosed DACA aneurysms.1,2 Customized revascularization with bypass, side-to-side anastomosis, and trapping of the aneurysmal segment have also been performed for treating DACA aneurysms.3-12 We present a 2-dimensional operative video of superficial temporal artery (STA) to distal anterior cerebral artery bypass, followed by trapping of the aneurysm-bearing segment. A 57-yr-old lady presented with a large ruptured subcallosal fusiform DACA aneurysm (WFNS grade 1, Fisher grade 1). Angiography revealed a 1.3 × 0.9 cm fusiform aneurysm in the DACA.  Informed consent was secured from the patient and her family for the surgery and permission was obtained for the publication of the patient's image/surgical video. The frontal and parietal branches of the STA were dissected. The parietal branch was explanted and used as a free interposition graft between the frontal branch (end-to-end anastomosis) and calloso-marginal artery (end-to-side anastomosis). After confirming blood flow through the bypass using Doppler, the aneurysm was trapped and excised.  The patient had an uneventful recovery. Her postoperative computed tomography (CT) head revealed no evidence of neurological insult. The patency of the bypass conduit and the complete removal of the aneurysm were confirmed using a digital subtraction angiogram. Histopathological examination revealed an eccentric atheromatous plaque with a lipid core. There was no evidence of intraplaque hemorrhage. This extended STA graft utilizing the frontal and parietal branches of the STA, and its implantation into the distal ACA, offers a novel bypass strategy for tackling fusiform aneurysms of the DACA. Anastomosis to the calloso-marginal artery ensured perfusion of the ACA territory through the pericallosal artery during temporary occlusion.

Interposition grafting for irreparable rotator cuff tears: Systematic review and specialist practice report

The treatment of symptomatic irreparable rotator cuff tears poses significant challenges to both patients and shoulder surgeons. Although reverse shoulder arthroplasty provides reliably good outcomes in the elderly, it is not a good option in younger patients. Various surgical techniques have been proposed for the treatment of irreparable rotator cuff tears; however, no gold standard currently exists. Interposition grafting is used when the rotator cuff cannot be fully repaired onto its footprint, and the remaining defect is bridged with either an allograft, autograft, xenograft or a synthetic graft. This review aims to present the literature on the use of various interposition grafts and techniques to treat large or massive irreparable rotator cuff tears and provide a specialist practice report.

Sandwich graft technique outcomes in medium and large size nasal septal perforations

Introduction

Surgical treatment of medium and large sized nasal septal perforation is challenging. Techniques with and without interposition grafts are used.

Objective

The aim of this study is to explain how we apply the sandwich graft technique that we use in medium and large nasal septal perforations as well as to present the results.

Methods

We retrospectively reviewed the patients who were operated with the sandwich graft technique between January 2014 to December 2018 and followed up for at least 6 months. The demographic data, symptom scores, examination, and surgical findings of the patients were taken from the hospital records. Surgical outcomes were presented according to both perforation etiologies (idiopathic or iatrogenic) and sizes (Group A: < 2 cm, Group B: ≥ 2 cm).

Results

We reviewed 52 cases and 56 surgeries. The average diameter of the perforations was 19.2 mm. The success rate after initial surgeries was 84.6% (44/52). After 4 revision surgeries, the perforation was closed in 88.5% of the cases (46/52). Success rates for Group A and Group B were 90.0% and 86.4%, respectively (p = 0.689). The success rates in idiopathic and iatrogenic cases were 93.3% and 86.5%, respectively (p = 0.659).

Conclusion

This study showed that the success rate of sandwich graft technique was higher in medium-sized perforations than large-sized ones and in idiopathic perforations compared to iatrogenic ones, but the latter rate was not statistically significant. This demonstrated that perforation size was not as important in the sandwich graft technique as in flap techniques.

Portal bifurcation reconstruction using own hepatic vein grafts due to portal vein anomaly of the living donor for the patient with portal vein thrombosis

A 57-year-old Japanese female was considered for living donor liver transplantation (LDLT) due to end-stage liver cirrhosis caused by primary biliary cholangitis with portal vein thrombosis (PVT) formation. A 26-year-old daughter of the patient was selected as a living donor; however, a computed tomography examination revealed trifurcated-type portal vein anomaly (PVA). Preoperative liver volumetry showed that the right lobe graft was necessary for the recipient; therefore, reconstruction of the portal vein bifurcation during LDLT was necessary. We planned to extract the recipient's own hepatic vein grafts after total hepatectomy, and these would be attached with anterior and posterior portal branches as jump grafts. We performed laparoscopic donor hepatectomy as usual, and the recipient's hepatic vein grafts were anastomosed on the bench. Then, the liver graft was inserted, and the hepatic vein reconstruction was routinely performed. We confirmed the alignment between the recipient's portal vein and the bridged hepatic vein graft of the liver graft's posterior branch, and anastomosed these two vessels. Moreover, we confirmed the front flow and expansion of the reconstructed posterior branch by declamping only the suprapancreatic side of the portal vein. The decision regarding the punch-out location was crucial. We confirmed the alignment between the reconstructed posterior branch and the bridged hepatic vein graft of the anterior branch, and anastomosed these two vessels employing the punched-out technique. In LDLT, liver transplant surgeons occasionally encounter living donors with PVA or recipients with PVT. Our contrivance may be useful when the liver graft needs reconstruction of portal vein bifurcation.

True Idiopathic Radial Artery Aneurysm: A Case Report and Review of Current Literature

Introduction

True non-traumatic radial artery aneurysms (RAAs) are extremely rare, and few cases have been described. The majority of RAAs are post-traumatic or iatrogenic pseudo-aneurysms following arterial cannulation. However, RAAs due to other causes have also been described. Here a rare case of true idiopathic distal RAA, which was managed by surgical resection and repair with interposition vein graft, is described.

Report

A 62 year old female with a known medical history of hypertension and hyperlipidaemia presented with left wrist swelling of one year duration, associated with a pulsatile lump that was increasing in size. Duplex ultrasound and computed tomography angiography revealed a distal RAA. She underwent open surgical resection and repair with interposition vein graft using the distal left cephalic vein. Histopathology of the specimen revealed an aneurysm with atherosclerosis. She recovered well post-operatively with no complications.

Discussion

True idiopathic RAAs are rare. Surgical treatment is almost always recommended in view of the risk of complications. A case of true idiopathic distal RAA is presented here, which was managed successfully by surgical resection and repair with interposition vein graft.

•

True radial artery aneurysms are extremely rare; most are post-traumatic or iatrogenic.

•

Options include observation, excision with ligation, primary repair or interposition graft.

•

Surgery is usually recommended due to risk of complications and has minimal morbidity.

A rare complication of myocardial ischaemia following single-stage repair in a case of Berry syndrome

Berry syndrome is a rare congenital cardiac lesion consisting of a distal aortopulmonary window, the aortic origin of the right pulmonary artery (PA), intact ventricular septum and an interrupted or hypoplastic aortic arch. Different repair techniques have been described in the literature. We report a case of Berry syndrome, in whom myocardial ischaemia developed following direct implantation of the right PA to the main PA, which was resolved using an interposition tube graft.

Middle Cerebral Artery-to-Middle Cerebral Artery Bypass with Superficial Temporal Artery Interposition Graft for the Treatment of Recurrent Thrombosed Middle Cerebral Artery Aneurysm

Microsurgical treatment of thrombosed middle cerebral artery (MCA) aneurysm is very complicated, especially in recurrent cases. A 48-year-old man presented with a recurrent thrombosed right MCA aneurysm. We performed MCA-to-MCA bypass using a superficial temporal artery (STA) interposition graft and proximal trapping. Initially, an STA-to-MCA bypass with aneurysm trapping was planned because 1 MCA branch of the superior trunk of the M2 segment needed flow replacement after aneurysm trapping. However, the blood flow from the proximal STA was insufficient because of the previous surgical trauma and redo clipping was not feasible. As the backflow from the distal STA segment was good, we used it as an interposition graft for the MCA-to-MCA bypass. The patient recovered well without any neurologic deficits. In this case, the recurrent aneurysm was a fusiform MCA-M2 segment aneurysm with clip slippage. Our initial surgical plan could not be executed. We changed our surgical plan to an MCA-interposition graft-MCA bypass considering the mobility of the M3 arteries. The options for interposition grafts included radial artery, saphenous vein, or ipsilateral or contralateral STA. The caliber discrepancy in the radial artery or saphenous vein grafts makes them less suitable. Further, harvesting the contralateral STA is time-consuming and tedious. Thus the ipsilateral STA interposition graft was used and showed promising results. We recommend this surgical technique in cases in which good STA backflow is guaranteed. In conclusion, revision surgery performed for a recurrent thrombosed MCA aneurysm with an MCA-STA interposition graft-MCA bypass with proximal trapping was successful. This technique is safe and effective for complex aneurysms with suboptimal condition of the STA, which could be due to reduced blood flow, previous surgery, or trauma.

Usability of Inferior Vena Cava Interposition Graft During Living Donor Liver Transplantation: Is This Approach Always Necessary?

PURPOSE

To share the outcome of caval reconstruction technique in patients who underwent living donor liver transplantation (LDLT) with inferior vena cava (IVC) interposition grafting.

METHODS

Between January 2009 and December 2018, an artificial or homologous interposition vascular graft was used for the continuity of resected native (IVC) due to various reasons in 29 of 1740 patients who underwent LDLT at our institute. Demographic, clinical, and radiological data were prospectively collected and retrospectively analyzed.

RESULTS

Sixteen female and 13 male patients ranging 6-67 years of age were included. Right, left, and left lobe lateral segments were used in 22, 5, and 2 patients, respectively. The three leading LDLT indications were primary or idiopathic Budd-Chiari syndrome (BCS) (n = 12), alveolar echinococcosis (n = 7), and secondary BCS (n = 5). The three leading indications for IVC interposition grafting were thrombosis, dense fibrosis, and IVC invasion caused by tumor or echinococcosis. Homologous IVC graft was used in 17, homologous aortic graft in 7, and Dacron graft in 5 patients. Throughout the follow-up period, ascites ± pleural effusion and elevated liver enzymes were detected in 12 and 4 patients, respectively. Stenosis and/or thrombosis requiring one or more procedures such as 1-6 sessions balloon angioplasty, stent, and thrombus aspiration were observed in half of the patients.

CONCLUSION

Retrohepatic IVC damages are not a contraindication for LDLT. The presence or absence of venous collateral circulation is an important indicator of the need for IVC interposition graft use.

Surgical Strategies for Cerebral Revascularization in Patients with Limited Bypass Conduit Options and Unexpected Intraoperative Difficulties

BACKGROUND

Cerebral bypass procedures are complex and require substantial experience and skills and thorough preoperative planning. Cerebrovascular surgeons face increasingly complex bypass cases because most routine cases are managed by endovascular means, and because increasing numbers of patients have complex medical problems that affect available and suitable bypass conduit options. We report the cases of several patients undergoing cerebral bypass with limited bypass conduit alternatives, in whom there were unexpected intraoperative difficulties requiring complex solutions.

METHODS

The neurological surgery department database was reviewed to identify patients who had undergone cerebral bypass procedures during a 13-year period in whom there were limited available bypass conduits, and in whom unexpected intraoperative difficulties were encountered during cerebral bypass.

RESULTS

Patient outcomes and graft patency were evaluated for 13 patients including 6 with ischemia, 3 with giant aneurysms, 2 with mycotic aneurysms, 1 with dissecting aneurysm, and 1 with gunshot-induced pseudoaneurysm. Median duration of follow-up was 43 months. In 12 of 13 patients, bypass graft/grafts were patent on the last computed tomography angiogram. In 1 patient, a prophylactic bypass procedure, the graft was not filling, probably because of lack of demand. Two patients died during follow-up of unrelated causes.

CONCLUSIONS

Cerebrovascular surgeons should be versatile in dealing with patients with complex bypass. When there are limited available conduit options, we find that collaboration with other surgical specialties (e.g., plastics and vascular) is helpful. In patients in whom extreme intraoperative difficulties are expected, thorough preoperative planning with multiple backup plans should be exercised, as described in this report.

Occipital Artery to Middle Cerebral Artery Bypass Using the Descending Branch of the Lateral Circumflex Femoral Artery as an Interposition Graft for Blood Flow Augmentation in Progressive Moyamoya Disease

BACKGROUND

The superficial temporal artery to middle cerebral artery (MCA) end-to-side anastomosis is the most commonly used direct extracranial-intracranial bypasses type for Moyamoya disease (MMD). In progressive MMD without suitable scalp arteries, other bypass constructs may need to be considered to augment blood flow.

CASE DESCRIPTION

We present the exceptional case of a 48-year-old woman with progressive MMD and repeated transient ischemic attacks originating from the right hemisphere despite previous bilateral bypasses. We used the descending branch of the lateral circumflex femoral artery as an interposition graft for an occipital artery to M4 MCA bypass with 2 end-to-side anastomoses to augment blood flow. The ipsilateral occipital artery had already formed bilateral transdural collaterals; the goal was to preserve its supply while using the artery as a donor for an interposition graft. Access to the Sylvian fissure was limited because of the previous superficial temporal artery to MCA bypass with an extensive superficial collateral network necessitating preservation. The posterior aspect of the Sylvian fissure was targeted to revascularize the posterior frontal and parietal region using an interposition graft matching the vessel size of a distal MCA vessel segment. Surgery was technically successful, without complications, and the patient recovered without new neurologic deficits. The bypass graft was patent on postoperative computed tomographic angiography and transcranioplasty ultrasound.

CONCLUSIONS

This case illustrates the need for creative bypass constructs in progressive MMD patients with multiple prior surgeries. Two surgical goals are paramount: flow augmentation with preservation of the existing collateral network to avoid complications and new deficits.

Superficial Temporal Artery Trunk-to-Middle Cerebral Artery Bypass with Short Radial Artery Interposition Graft for Symptomatic Internal Carotid Artery Occlusion

OBJECTIVE

We investigated the use of high-flow superficial temporal artery trunk-to-radial artery-to-middle cerebral artery (STAt-RA-MCA) bypass to prevent ischemic stroke in patients with symptomatic internal carotid artery occlusion (SICAO).

METHODS

We retrospectively analyzed the data from patients with SICAO who had undergone high-flow STAt-RA-MCA bypass in our center from October 2014 to November 2017. The incidence of ischemic stroke, changes in cerebral blood flow, characteristics of perioperative complications, and related factors determining the blood flow rate in the graft were analyzed.

RESULTS

From October 2014 to November 2017, we treated 21 patients with SICAO using high-flow STAt-RA-MCA bypass. A total of 42 ischemic stroke events had been reported within 6 months before surgery. The ipsilateral/contralateral mean transit time (I/C MTT) ratio before surgery was 1.24 ± 0.10 (range, 1.14-1.51). During a median follow-up period of 692 days (range, 212-1114), 3 transient ischemic attacks occurred in 3 patients; 18 patients (85.7%) did not experience recurrent stroke. The patency rate of the bypass graft was 95.2% (20 of 21). The I/C MTT ratio was 1.06 ± 0.11 on postoperative day 1 in all patients and was significantly different from the preoperative I/C MTT ratio (P < 0.001). The surgical complication rate was 9.5% (2 of 21), and no reoperation was required.

CONCLUSION

Our results suggest that high-flow STAt-RA-MCA bypass can effectively reduce the risk of stroke in patients with SICAO. Moreover, the surgical procedure is a highly safe procedure. Further randomized controlled studies are required to draw more precise conclusions.

The Infrazygomatic Segment of the Superficial Temporal Artery: Anatomy and Technique for Harvesting a Better Interposition Graft

BACKGROUND

The superficial temporal artery (STA) is underutilized as an interposition graft because current techniques expose and harvest STA above the level of the zygoma. This technique yields a diminutive arterial segment in both length and diameter, which limits its use for extracranial-intracranial bypass.

OBJECTIVE

To introduce a safe and efficient technique for harvesting of the infrazygomatic segment of the STA.

METHODS

Scalp layers, STA, and the facial nerve were studied in 18 specimens. The length of the STA segment harvested below the superior border of the zygomatic arch was measured. Safety of this technique was assessed by measuring the distance between the facial nerve and the STA.

RESULTS

The galea and subgaleal fat pad were the only anatomical planes found between the facial nerve and the STA below the zygomatic arch. A dense subcutaneous band of galea contained the STA and allowed proximal dissection of the artery without exposing the facial nerve. The average length of the artery harvested between the zygomatic arch and the parotid gland was 20 mm.

CONCLUSION

Subcutaneous dissection within the galea below the level of the zygomatic arch and preservation of the dense subcutaneous band surrounding the STA avoids transecting the facial nerve branches while providing increased STA exposure. This anatomical knowledge may increase the use of STA as an interposition graft in cerebrovascular bypass procedures and reduce the need to harvest grafts through additional incisions at remote sites.

Angulating-Distraction Ulnar Osteotomy and Interpositional Phosphocalcic Ceramic Wedge Graft for a Chronic Monteggia Lesion

Background:

Various types of osteotomies have been used to facilitate reduction of the radial head and to prevent recurrent subluxation. The Bouyala technique – open reduction of radial head associated with open wedge ulnar osteotomy with or without annular ligament reconstruction, is presently the most widely used treatment for long- standing traumatic dislocation of the radial head, independently of age, in the absence of osteoarthritis remodeling, and should preferably be performed within 1 year of trauma.

Method:

In this article, we present a similar case operated by same technique, but we used synthetic phosphocalcic ceramic wedge graft instead of auto bone graft as described in many other studies. We believe that, this will limit the donor site morbidity and also aid in achieving better stability at osteotomy site, which in turn help in proceeding with early active mobilization protocol.

Result:

We achieved union of the osteotomy by three months. Clinically, there was no deformity and she achieved full pain-free range of motion of elbow joint.

Conclusion:

We believe that, use of synthetic phosphocalcic ceramic wedge graft allow rigid fixation of osteotomy, provides additional stability, decrease the risk of secondary displacement and allow early mobilization, which may minimize contracture and we could achieve fairly good clinical outcome.

Endonasal septal perforation repair using posterior and inferiorly based mucosal rotation flaps

IMPORTANCE

Repair of nasal septal perforations is challenging regardless of surgical technique due to their location and the health of surrounding tissue. There is currently no surgical procedure which is completely effective in the treatment of anteriorly located perforations.

OBJECTIVE

To report a novel method of closing anterior septal perforations using an inferiorly based mucosal rotation flap and an acellular dermal interposition graft, as well as expand upon a previous series.

DESIGN

The study includes patients who underwent surgical repair for septal perforations by the senior author between 2003 and 2015.

SETTING

The study took place at MetroHealth Medical Center in Cleveland, Ohio.

PARTICIPANTS

Thirty-nine patients (15 male) with septal perforations of various size and etiology underwent endonasal repair using rotation flaps. The average age of patients was 42-years old (range 10-67years). INTERVENTION FOR CLINICAL TRIALS OR EXPOSURE FOR OBSERVATIONAL STUDIES: Five patients had perforations such that we used inferiorly based flaps, while 35 cases utilized posteriorly based flaps. Acellular dermis was used in addition to a unilateral rotation flap.

MAIN OUTCOMES AND MEASURES

The primary outcome desired was a complete closure of the septal perforation. The success, or lack thereof, was monitored after healing from surgery.

RESULTS

Thirty-seven of the forty surgical procedures demonstrated complete closure of the perforation, a 92.5% success rate. Perforations were separated based upon size. Small perforations (<1cm) had a 93.3% success rate, medium (1-2cm) 88.9%, and all seven large perforations (>2cm) were closed successfully. In addition, all five of the inferiorly based procedures resulted in complete closure of the perforation. Of the failed repairs, one required revision surgery to repair a recurring perforation, while the other two were asymptomatic following the procedure.

CONCLUSIONS AND RELEVANCE

Endonasal repair using inferiorly based mucosal rotation flaps coupled with an acellular dermal interposition graft is a valid technique for the repair of septal perforations. Posterior rotation flaps are preferred due to major septal blood supply from branches of the sphenopalatine artery, but inferiorly based flaps are also viable options for repair for perforations located in the anterior septum.

Double localization of a non-anastomotic pseudoaneurysm after an axillofemoral bypass: a case report and review of the literature

Background

A traumatic non-anastomotic pseudoaneurysm is a rare complication of an axillofemoral bypass graft. Fewer than 20 cases have been reported in the literature. Our case is unusual in that we report a double localization of this complication.

Case presentation

We report the case of a 60-year-old Arabic male patient who was diagnosed with two hematomas in the trajectory of his axillofemoral bypass secondary to a traumatism. The diagnosis of a non-anastomotic pseudoaneurysm was retained considering the results of a computed tomography angiography scan, which showed the double localization of the pseudoaneurysm. Surgical management consisted of flattening the pseudoaneurysm along with the interposition of a prosthetic segment. There were no postoperative complications and our patient was well 3 years after discharge.

Conclusions

Non-anastomotic pseudoaneurysm is a rarely described complication of a axillofemoral bypass graft. To the best of our knowledge, a double localization has not been described in the literature before. Minimally invasive techniques as a treatment option are being widely used as an alternative to open repair.

The Aetiology, Treatment, and Outcome of Urogenital Fistulae Managed in Well- and Low-resourced Countries: A Systematic Review

CONTEXT

Urogenital fistula is a global healthcare problem, predominantly associated with obstetric complications in low-resourced countries and iatrogenic injury in well-resourced countries. Currently, the published evidence is of relatively low quality, mainly consisting retrospective case series.

OBJECTIVE

We evaluated the available evidence for aetiology, intervention, and outcomes of urogenital fistulae worldwide.

EVIDENCE ACQUISITION

We performed a systematic review of the PubMed and Scopus databases, classifying the evidence for fistula aetiology, repair techniques, and outcomes of surgery. Comparisons were made between fistulae treated in well-resourced countries and those in low-resourced countries.

EVIDENCE SYNTHESIS

Over a 35-yr period, 49 articles were identified using our search criteria, which were included in the qualitative analysis. In well-resourced countries, 1710/2055 (83.2%) of fistulae occurred following surgery, whereas in low-resourced countries, 9902/10398 (95.2%) were associated with childbirth. Spontaneous closure can occur in up to 15% of cases using catheter drainage and conservative approaches are more likely to be successful for nonradiotherapy fistulae. Of patients undergoing repairs in well-resourced countries, the median overall closure rate was 94.6%, while in low-resourced countries, this was 87.0%. Closure was significantly more likely to be achieved using a transvaginal approach then a transabdominal technique (90.8% success vs 83.9%, Fisher's exact test; p=0.0176).

CONCLUSIONS

It is difficult to conclude whether any specific route of surgery has advantage over any other, given the selection of patients to a particular procedure is based upon individual fistula characteristics. However, surgical repair should be carried out by experienced fistula surgeons, well versed in all techniques as the primary attempt at repair is likely to be the most successful.

PATIENT SUMMARY

Urogenital fistulae are a common problem worldwide; however, the available evidence on fistula management is poor in quality. We searched the current literature and identified that 95% of fistulae occur following childbirth in low-resourced countries, whereas 80% of fistulae are associated with surgery in well-resourced countries, where successful repair is also more likely to be achieved. The first attempt at repair is often the most successful and therefore fistula surgery should be centralised to hospitals with the most experience.

Standardized surgical techniques for adult living donor liver transplantation using a modified right lobe graft: a video presentation from bench to reperfusion

After having experienced more than 2,000 cases of adult living donor liver transplantation (LDLT), we established the concepts of right liver graft standardization. Right liver graft standardization intends to provide hemodynamics-based and regeneration-compliant reconstruction of vascular inflow and outflow. Right liver graft standardization consists of the following components: Right hepatic vein reconstruction includes a combination of caudal-side deep incision and patch venoplasty of the graft right hepatic vein to remove the acute angle between the graft right hepatic vein and the inferior vena cava; middle hepatic vein reconstruction includes interposition of a uniform-shaped conduit with large-sized homologous or prosthetic grafts; if the inferior right hepatic vein is present, its reconstruction includes funneling and unification venoplasty for multiple short hepatic veins; if donor portal vein anomaly is present, its reconstruction includes conjoined unification venoplasty for two or more portal vein orifices. This video clip that shows the surgical technique from bench to reperfusion was a case presentation of adult LDLT using a modified right liver graft from the patient's son. Our intention behind proposing the concept of right liver graft standardization is that it can be universally applicable and may guarantee nearly the same outcomes regardless of the surgeon's experience. We believe that this reconstruction model would be primarily applied to a majority of adult LDLT cases.

Repair of adult aortic coarctation by resection and interposition grafting

OBJECTIVES

Aortic coarctation presenting during adult life most frequently represents cases of re-coarctation, following previous transcatheter or surgical therapy, or missed cases of native coarctation. In the area of evolving endovascular therapy, we believe that there is still a place for durable open repair by means of resection and interposition grafting. We, therefore, evaluated our results in adult patients with primary aortic coarctation or complications of a previous coarctation repair.

METHODS

A total of 38 patients were operated between 1989 and 2014. Median age was 43 years (range 18-69 years), and 20 were male (52.6%). Seventeen patients (44.7%) had recurrent coarctation or dilatation after previous repair during childhood; the remaining 21 (55.3%) had primary coarctation diagnosed at adult age. Data were retrospectively reviewed and analysed for indications, type of repair, operative details and outcomes.

RESULTS

Resection and interposition grafting was performed primarily with the use of left-left bypass (mean cross-clamping time 41 ± 13 min). There were no in-hospital deaths, stroke, spinal cord ischaemia, renal or respiratory failure. No patient had evidence of symptomatic aortic re-coarctation or pseudoaneurysm formation on follow-up. Long-term survival after 20 years was 94.7%.

CONCLUSIONS

Open surgical repair of primary, recurrent or complicated adult aortic coarctation by interposition grafting is a safe and feasible therapeutic option, providing durable long-term results and excellent long-term survival.

A hypothesis-driven parametric study of effects of polymeric scaffold properties on tissue engineered neovessel formation

Continued advances in the tissue engineering of vascular grafts have enabled a paradigm shift from the desire to design for adequate suture retention, burst pressure and thrombo-resistance to the goal of achieving grafts having near native properties, including growth potential. Achieving this far more ambitious outcome will require the identification of optimal, not just adequate, scaffold structure and material properties. Given the myriad possible combinations of scaffold parameters, there is a need for a new strategy for reducing the experimental search space. Toward this end, we present a new modeling framework for in vivo neovessel development that allows one to begin to assess in silico the potential consequences of different combinations of scaffold structure and material properties. To restrict the number of parameters considered, we also utilize a non-dimensionalization to identify key properties of interest. Using illustrative constitutive relations for both the evolving fibrous scaffold and the neotissue that develops in response to inflammatory and mechanobiological cues, we show that this combined non-dimensionalization computational approach predicts salient aspects of neotissue development that depend directly on two key scaffold parameters, porosity and fiber diameter. We suggest, therefore, that hypothesis-driven computational models should continue to be pursued given their potential to identify preferred combinations of scaffold parameters that have the promise of improving neovessel outcome. In this way, we can begin to move beyond a purely empirical trial-and-error search for optimal combinations of parameters and instead focus our experimental resources on those combinations that are predicted to have the most promise.

Computational model of the in vivo development of a tissue engineered vein from an implanted polymeric construct

Advances in vascular tissue engineering have been tremendous over the past 15 years, yet there remains a need to optimize current constructs to achieve vessels having true growth potential. Toward this end, it has been suggested that computational models may help hasten this process by enabling time-efficient parametric studies that can reduce the experimental search space. In this paper, we present a first generation computational model for describing the in vivo development of a tissue engineered vein from an implanted polymeric scaffold. The model was motivated by our recent data on the evolution of mechanical properties and microstructural composition over 24 weeks in a mouse inferior vena cava interposition graft. It is shown that these data can be captured well by including both an early inflammatory-mediated and a subsequent mechano-mediated production of extracellular matrix. There remains a pressing need, however, for more data to inform the development of next generation models, particularly the precise transition from the inflammatory to the mechanobiological dominated production of matrix having functional capability.