Long-term outcomes of autologous vein bypass for repair of upper and lower extremity major arterial trauma

OBJECTIVE

Autologous vein is the preferred bypass conduit for extremity arterial injuries owing to superior patency and low infection risk; however, long-term data on outcomes in civilians are limited. Our goal was to assess short- and long-term outcomes of autologous vein bypass for upper and lower extremity arterial trauma.

METHODS

A retrospective review was performed of patients with major extremity arterial injuries (2001-2019) at a level I trauma center. Demographics, injury and intervention details, and outcomes were recorded. Primary outcomes were primary patency at 1 year and 3 years. Secondary outcomes were limb function at 6 months, major amputation, and mortality. Multivariable analysis determined risk factors for functional impairment.

RESULTS

There were 107 extremity arterial injuries (31.8% upper and 68.2% lower) treated with autologous vein bypass. Mechanism was penetrating in 77% of cases, of which 79.3% were due to firearms. The most frequently injured vessels were the common and superficial femoral (38%), popliteal (30%), and brachial arteries (29%). For upper extremity trauma, concomitant nerve and orthopedic injuries were found in 15 (44.1%) and 11 (32.4%) cases, respectively. For lower extremities, concomitant nerve injuries were found in 10 (13.7%) cases, and orthopedic injuries in 31 (42.5%). Great saphenous vein was the conduit in 96% of cases. Immediate intraoperative bypass revision occurred in 9.3% of patients, most commonly for graft thrombosis. The in-hospital return to operating room rate was 15.9%, with graft thrombosis (47.1%) and wound infections (23.5%) being the most common reasons. The median follow-up was 3.6 years. Kaplan-Meier analysis showed 92% primary patency at 1 year and 90% at 3 years. At 6 months, 36.1% of patients had functional impairment. Of patients with functional impairment at 6 months, 62.9% had concomitant nerve and 60% concomitant orthopedic injuries. Of those with nerve injury, 91.7% had functional impairment, compared with 17.8% without nerve injury (P < .001). Of patients with orthopedic injuries, 51.2% had functional impairment, vs 25% of those without orthopedic injuries (P = .01). On multivariable analysis, concomitant nerve injury (odds ratio, 127.4; 95% confidence interval, 17-957; P <. 001) and immediate intraoperative revision (odds ratio, 11.03; 95% confidence interval, 1.27-95.55; P = .029) were associated with functional impairment.

CONCLUSIONS

Autologous vein bypass for major extremity arterial trauma is durable; however, many patients have long-term limb dysfunction associated with concomitant nerve injury and immediate intraoperative bypass revision. These factors may allow clinicians to identify patients at higher risk for functional impairment, to outline patient expectations and direct rehabilitation efforts toward improving functional outcomes.

Technical Aspects of Percutaneous Deep Venous Arterialization Using Off-the-Shelf Devices

PURPOSE

Chronic limb-threatening ischemia (CLTI) represents the clinical end stage of lower extremity peripheral arterial disease (PAD). Although conventional open and endovascular revascularization options are available, some CLTI patients do not respond to these treatments, generally due to small vessel occlusive disease, with only limited or no clinical improvement achieved. This article aims to provide insights related to pertinent venous anatomy of the leg and below the ankle and a technical review of percutaneous deep venous arterialization (pDVA) creation using commonly-available devices.

TECHNIQUE

For patients with "no-option" CLTI, the risk of major amputation and mortality remains high. Although arterial revascularization remains the optimal treatment of CLTI, some patients with severely-diseased or gracile distal arteries have poor outcome. Deep venous arterialization (DVA), in a subset of patients with tibial anatomy amenable to DVA creation, represents the last-ditch attempt before these patients are deemed to have "no-hope" at limb salvage, and major amputation becomes necessary. Refinement in technique and advancement in device development have been shown to allow pDVA to be created with respectable outcomes for the "no-option" CLTI patient population.

CONCLUSION

The pDVA has garnered increasing interest among endovascular specialists to further understand the anatomical and technical key points of this procedure, and it may yet prove to be a useful addition in the armamentarium in our battle against CLTI.

CLINICAL IMPACT

Percutaneous deep venous arterialisation provides another option in the treatment of challenging "no-option" CLTI patients, and off-the-shelf devices will allow this procedure to be performed in centers where dedicated devices are not available.

Comparison of Arterial and Venous Interposition Grafting for Arterial Defects in a Rat Model

BACKGROUND

 Interposition microvascular grafting may be required to bridge arterial defects during digital replantation or revascularization and has traditionally been performed utilizing a venous autograft. Arterial interposition grafting has been shown to be superior in maintaining patency in large vessel surgery; there are case reports of its use in microsurgery.

METHODS

 Six fellowship-trained hand and microsurgeons performed arterial and venous interposition grafts on the femoral arteries of 40 Wistar rats. After sectioning one femoral artery a segment of the contralateral femoral artery or vein was obtained. The time was recorded per graft and patency tested 10 minutes following grafting by an independent assessor. Each surgeon also completed a questionnaire detailing regular microsurgical volume, technical ease, and conceptual preference for either graft.

RESULTS

 Time for arterial interposition (median time 51.7 minutes) was longer than venous grafting (median time 45.9 minutes, p = 0.075). Arterial grafts were more likely to be patent or questionably patent (odds ratio [OR] = 6.77, p = 0.031). All surgeons found arterial interposition grafting technically easier and preferred it conceptually. Improvements were noted in patency rates (OR = 11.29, p = 0.018) and avoidance of anastomotic leak (OR = 0.19, p = 0.029) when surgeons performed moderate levels or greater of microsurgery within their regular practice.

CONCLUSION

 Greater immediate patency was noted with arterial interposition grafting in a rodent model when compared to venous grafting, although procedural time was greater. All surgeons found arterial grafting technically easier. Arterial microvascular grafting may be useful in the setting of digital replantation or revascularization with an arterial defect.

Robot-assisted lymphovenous anastomosis surgery for lymphocele in the groin

We present the first-in-human robot-assisted microsurgery on a lymphocele in the groin involving a man in his late 60s who had been coping with the condition for 12 months. Despite numerous efforts at conservative treatment and surgical intervention, the lymphocele persisted, leading to a referral to our clinic.Diagnostic techniques, including indocyanine green lymphography and ultrasound, identified one lymphatic vessel draining into the lymphocele. The surgical intervention, conducted with the assistance of a robot and facilitated by the Symani Surgical System (Medical Microinstruments, Calci, Italy), involved a lymphovenous anastomosis and excision of the lymphocele. An end-to-end anastomosis was performed between the lymphatic and venous vessels measuring 1 mm in diameter, using an Ethilon 10-0 suture.The surgery was successful, with no postoperative complications and a prompt recovery. The patient was discharged 3 days postoperatively and exhibited complete recovery at the 14-day follow-up. This case marks the first use of robot-assisted microsurgical lymphovenous anastomosis to address a groin lymphocele, highlighting the benefit of advanced robotic technology in complex lymphatic surgeries.

Novel classification of proximal forearm perforator vein in the planning and creation of percutaneous and surgical Gracz-type arteriovenous fistulae

BACKGROUND

The perforator vein determines whether it is feasible to create a percutaneous (pAVF) or surgical "Gracz-type" arteriovenous fistula (sAVF). Creating a standard anatomic classification of the antecubital region is beneficial to both the selection of the appropriate device and/or procedure and technical outcomes. Accordingly, an analysis of a large cohort of patients undergoing pAVF/sAVF was performed, focusing on perforator vein anatomical suitability, and a novel anatomical classification of the antecubital region was developed and proposed.

METHODS

Between August 2018 and July 2022, chronic or end-stage kidney disease patients as well as patients anticipated an initiation of apheresis, who were referred for vascular access planning, underwent a standardized evaluation of upper extremities. A vessel mapping summary detailing the vasculature and the access creation plan was completed, indicating the anatomical suitability for sAVF and pAVF (Ellipsys and WavelinQ) techniques.

RESULTS

Of 524 patients, 36.5% were female (average age 65 years). 53.2% were on dialysis, 41.6% had diabetes, and 13.2% had a previously failed permanent dialysis access. The anatomy for successful pAVF creation was judged to be suitable in 54% of patients for an Ellipsys-pAVF, and 29.8% for WavelinQ-pAVF. Of the WavelinQ group, 54.4% had suitable anatomy for ulnar, 26.9% for radial, and 18.6% for both ulnar/radial anastomoses. Additionally, 60.7% had suitable anatomy for pAVF creation with at least one of the systems, while 22.5% were suited for both types of pAVF-systems. 80.3% were candidates for creation of a Gracz-AVF.

CONCLUSION

Overall, we found that about 60% of patients are likely candidates for a pAVF, with 80% being candidates for creation of a Gracz-AVF. Male patients have significantly higher suitability for most types of AVF creation, and younger patients are more suitable for Ellipsys-pAVF and RCAVFs. Most importantly, a universal classification of perforator vein was developed, which is indispensable in modern vascular access planning.

Supermicrosurgical lymphovenous anastomosis

Lymphedema impairs patients' function and quality of life. Currently, supermicrosurgical lymphovenous anastomosis (LVA) is regarded as a significant and effective treatment for lymphedema. This article aims to review recent literature on this procedure, serving as a reference for future research and surgical advancements. Evolving since the last century, LVA has emerged as a pivotal domain within modern microsurgery. It plays a crucial role in treating lymphatic disorders. Recent literature discusses clinical imaging, surgical techniques, postoperative care, and efficacy. Combining advanced tools, precise imaging, and surgical skills, LVA provides a safer and more effective treatment option for lymphedema patients, significantly enhancing their quality of life. This procedure also presents new challenges and opportunities in the realm of microsurgery.

The difference in diameter between radial artery and cephalic vein correlates with primary patency of radio-cephalic arteriovenous fistula

INTRODUCTION

Autogenous radio-cephalic arteriovenous fistula (RCAVF) is preferred for chronic hemodialysis access. However, RCAVF still suffers from disappointing survival due to fistula dysfunction, with intimal hyperplasia (IH) as an underlying cause of this condition. The inconsistency of radial artery diameter (DRA) and cephalic vein diameter (DCV) is one of the factors affecting the shear disturbance, which is believed to trigger the onset of IH. However, there are no reports correlating the difference in DRA and DCV with RCAVF outcomes.

METHODS

This was a retrospective cohort study. Consecutive patients (n = 233) with a new RCAVF created were included if they underwent duplex ultrasound examination to evaluate preoperatively the radial artery diameter (DRA) and cephalic venous diameter (DCV). We then calculated radial artery-cephalic vein diameter difference (DCV minus DRA, termed DCV-DRA hereafter) and evaluated the association of the preoperative DCV-DRA with primary patency of RCAVF at 12 months. Subgroup analysis was also performed to explore effect modification by age, gender, radial artery diameter, and cephalic vein diameter with DCV-DRA.

RESULTS

After adjusting for age, gender, weight, and mean arterial pressure, the preoperative DCV-DRA was associated with primary patency of RCAVF at 12 months (adjusted Odds ratio [aOR], 1.524 per 1-mm increase; 95% confidence interval [95% CI], 1.048-2.218). The primary patency of RCAVF at 12 months was achieved in 69.4%, 71.8%,and 87.3% of patients with a preoperative DCV-DRA of ⩽-0.6 mm, (-0.5)-0.5 mm, and ⩾0.6 mm, respectively. P for trend was 0.029. Patients with DCV-DRA of ⩾0.6 mm had a much higher chance of 12-month patency than patients with DCV-DRA of ⩽-0.6 mm (aOR, 3.574; 95% CI, 1.276-10.010). Age, gender, radial artery diameter, and cephalic vein diameter did not modify the association of DCV-DRA with primary patency of RCAVF at 12 months.

CONCLUSIONS

Preoperative DCV-DRA may be an under-recognized predictor of RCAVF patency.

Modified no-touch technique for radio-cephalic arteriovenous fistula increases primary patency and decreases juxta-anastomotic stenosis

OBJECTIVE

Low primary patency rate is a major problem of radio-cephalic arteriovenous fistula (RC-AVF) creation. Radial artery deviation and reimplantation (RADAR) is associated with low juxta-anastomotic stenosis rate. However, inflow artery stenosis is prominent with RADAR. To further reduce injury to veins and arteries during operation, a modified no-touch technique (MNTT) was used to create RC-AVF.

METHODS

We retrospectively reviewed our prospectively maintained database of patients with end-stage renal disease (ESRD)s undergoing RC-AVF creation for hemodialysis using either the MNTT between January 2021 and January 2022 (MNTT group) or conventional surgical procedure ( end-to-side vein-to-artery anastomosis) between October 2016 and October 2017 (Control group). Patients who chose to undergo RC-AVF surgery underwent standardized preoperative mapping and postoperative fistula evaluations using duplex ultrasound. Additionally, 4D flow MRI data were used to visualize and quantify the hemodynamics of one RC-AVF by MNTT. Outcomes included primary patency, juxta-anastomotic stenosis, and maturation rates.

RESULTS

Forty patients underwent RC-AVFs by MNTT, compared to 60 patients in the control group. The MNTT group had a higher primary unassisted patency rate than the control group (p = 0.038). Juxta-anastomotic stenosis (all on the cephalic vein) occurred in 4 (10%) patients who underwent MNTT. RC-AVF maturation rates after 3 months were not different between both groups (maturation rate: 90% and 81.7% in the MNTT and control groups, respectively, p = 0.253). COX regression showed that both conventional AVF surgery (p = 0.031) and smaller cephalic vein diameter (p = 0.034) were associated with higher odds of RC-AVF failure. The AVF flow within the proximal vein remained helical during cardiac cycle. The distribution of wall shear stress (WSS) and oscillatory shear index (OSI) differed from that of conventional surgical AVF.

CONCLUSION

RC-AVF by MNTT increases primary patency rate and decreases juxta-anastomotic stenosis rate. The improvement in hemodynamics may be one of the important reasons for the better patency rate of in the RC-AVF by MNTT group.

One versus two vein anastomoses in breast reconstruction with a profunda artery perforator flap-does it make a difference

BACKGROUND

The profunda artery perforator (PAP) flap has gained popularity as a reliable alternative in breast reconstruction. Extensive research has focused on its vascular supply, dissection techniques, and broader applications beyond breast reconstruction. This study aims to investigate the correlation between the number of veins anastomosed for the PAP flap and postoperative complications.

METHODS

A retrospective study was conducted to evaluate the outcomes of breast reconstructions with PAP flaps at our institution between 2018 and 2022. A total of 103 PAP flaps in 88 patients were included. Statistical analysis was performed to compare outcomes between flaps with one vein anastomosis and those with two vein anastomoses. Patient characteristics, intra and postoperative parameters were analysed.

RESULTS

One vein anastomosis was used in 36 flaps (35.0%), whereas two vein anastomoses were used in 67 flaps (65.0%). No significant differences were found in patient characteristics between the one vein and two vein groups. The comparison of ischemia times between flaps with one versus two veins revealed no statistically significant difference, with mean ischemia times of 56.2 ± 36.8 min and 58.7 ± 33.0 min, respectively. Regarding outcomes, there were no statistically significant differences in secondary lipofilling, revision of vein anastomosis, or total flap loss between the two groups. Fat necrosis was observed in 5 (13.9%) one vein flaps and 5 (7.5%) two vein flaps, indicating no statistically significant difference between the two groups (p = .313). In the one vein group, the most frequently employed coupler ring had a diameter of 2.5 mm. In the two vein group, the most prevalent combination consisted of a 2.0 mm diameter with a 2.5 mm diameter.

CONCLUSION

Based on our study results, both one vein anastomosis and two vein anastomoses are viable options for breast reconstruction with PAP flap. The utilization of either one or two veins did not significantly affect ischemia time or flap loss. Fat necrosis exhibited a higher incidence in the single-vein group; however, this difference was also not statistically significant. These findings underscore the effectiveness of both approaches, providing surgeons with flexibility in tailoring their surgical techniques based on patient-specific considerations and anatomical factors.

The impact of stent-graft sizing on venous stenosis re-intervention and arteriovenous graft patency: Free-floating stent outflow is associated with improved outcomes

BACKGROUND

Early cannulation arteriovenous grafts (ecAVG) for dialysis access are limited by reintervention for venous stenosis (VS) despite their good initial patency. Whilst stent-grafts (SG) have shown promise, the optimal sizing is unclear. Therefore, this study aims to determine if outflow vein diameter, SG diameter or these relative to each other (V:Sr) alters outcomes, and if so, which is more important.

METHODS

Retrospective analysis was performed of Gore® Acuseal® ecAVGs with VS treated with Gore® Viabahn® SG over a 7-year period. Primary patency (PP), time to thrombosis and functional patency were analysed by SG length/diameter, vein diameter and V:Sr.

RESULTS

We identified 114 ecAVGs with median follow-up 492 days (IQR 189-770). SG length and diameter did not correlate with PP, however, there was a significant relationship between vein diameter and PP (RR = 0.901 (0.832-0.975), p = 0.01) and between V:Sr and PP (RR = 0.462 (0.255-0.838), x2 = 5.866, p = 0.0015). The optimal V:Sr was ⩾1.4 (i.e. vein diameter at least 40% greater than the stent-graft; or 'free-floating' stent outflow) (RR = 2.759 (1.670-4.558), p < 0.001), translating to a difference in median PP of 252 versus 496 days (IQR: 188-316; 322-670). On multivariate analysis, absolute vein diameter lost significance, whilst V:Sr remained an independently significant predictor of PP (RR = 3.247 (1.560-6.759), p = 0.02).

CONCLUSIONS

Placement of the SG outflow into a relatively larger segment of vein was associated with a significant increase in PP independent of the absolute vein diameter. This suggests that larger calibre SG which are apposed to the vein wall are not required for optimal primary patency, and indeed should be actively avoided. Instead, a 'free-floating' stent outflow which is undersized relative to the recipient vein (whilst maintaining a minimum anchoring calibre) is recommended where possible. This should be considered during intervention and may require selection of longer devices, where practical, to bring the stent outflow into a larger vein segment.

LEVEL OF EVIDENCE

Level 3a, Non-randomised controlled cohort/follow-up study.

Surgical versus medical management of patients with primary hyperaldosteronism and indeterminate adrenal vein sampling: A 10-year experience of the Cleveland Clinic

In patients with primary hyperaldosteronism (PA), adrenal vein sampling (AVS) can identify patients suitable for unilateral adrenalectomy. However, in AVS with an indeterminate aldosterone-to-cortisol lateralization (ACL) ratio of 3.0-4.0, clinical guidance is unclear. The authors screened all patients undergoing AVS at the Cleveland Clinic from October 2010 to January 2021 and identified 18 patients with indeterminate ACL results. Ten underwent adrenalectomy and eight continued medical management. The surgical group was younger (58.5 vs. 68 years, p = .17), and more likely to have a unilateral imaging adrenal abnormality (90% vs. 38%, p = .043) and a lower contralateral suppression index (0.63 vs. 1.1, p = .14). Post-treatment, the surgical group had a significant reduction in diastolic blood pressure (-5.5 mmHg, p = .043) and aldosterone (4.40 vs. 35.80 ng/mL, p = .035) and required fewer anti-hypertensive medications (2 vs. 3, p = .015). These findings may support the benefit of adrenalectomy in a select group of patients with indeterminate ACL.

Short-term mortality and revisions to promote maturation after arteriovenous fistula creation

OBJECTIVE

Arteriovenous fistula (AVF) for hemodialysis access is traditionally considered superior to grafts due to infection resistance and purported improved patency. However, challenges to AVF maturation and limited patient survival may reduce AVF benefits. The objective of this study is to identify factors associated with risk of AVF requiring revision before maturation and/or mortality within 2 years of creation.

METHODS

We performed a retrospective review of 250 AVFs created between May 2017 and November 2020 at a single institution. Maturation was defined as the date the surgeon deemed the AVF ready for use or the patient successfully used the AVF for dialysis. The Risk Analysis Index was used to calculate frailty. The primary outcome was a composite of endovascular/surgical revision to promote maturation and/or mortality within 2 years of AVF creation (REVDEAD). The primary outcome was categorized as met if the patient required a revision to promote maturation or if the patient experienced mortality within 2 years of AVF creation, or if both occurred. REVDEAD was compared with those who did not meet the primary outcome and will be referred to as NOREVDEAD.

RESULTS

Survival at 2 years after AVF creation was 82%, and 54 (22%) patients underwent AVF revision. Of those, 31 (59%) patients progressed to AVF maturation. Of the 250 AVFs, 91 (36%) met the primary outcome of REVDEAD and 159 (64%) did not (NOREVDEAD). There was no difference between the REVDEAD and NOREVDEAD groups in age (P = .18), sex (P = .75), White race (P = .97), Hispanic ethnicity (P = .62), obesity (P = .76), coronary artery disease (P = .07), congestive heart failure (P = .29), diabetes mellitus (P = .78), chronic obstructive pulmonary disease (P = .10), dialysis status (P = .63), hypertension (P = .32), peripheral arterial disease (P = .34), or dysrhythmia (P = .13). There was no difference between the groups in the forearm vs the upper arm location of AVF (P = .42) or the vein diameter (P = .58). Forearm access, as opposed to upper arm AVF creation, was associated with higher rate of revision before maturation (P = .05). More patients in REVDEAD were frail or very frail (60% vs 48%, P = .05). Of the AVFs that matured, maturation required longer time in REVDEAD at 110.0 ± 9.1 days vs 78.8 ± 5.6 days (mean ± standard deviation) (P = .003). Adjusted for the vein diameter and the forearm vs the upper arm, frailty increased the odds of REVDEAD by 1.9 (95% confidence interval: 1.1, 3.3).

CONCLUSIONS

Frail patients who underwent AVF were significantly more likely to die within 2 years of AVF creation with no significant association between frailty and the need for revisions to promote maturation. Forearm AVFs were more likely to require revisions; in patients who are frail, with a high likelihood of 2-year mortality, graft may be more appropriate than AVF. If AVF is being considered in a frail patient, upper arm AVFs should be prioritized over forearm AVFs.

Surgical Management of Vascular Malformations of the Upper Extremity: A 12-Year Retrospective Cohort Study

INTRODUCTION

Vascular malformations (VMs) typically appear at birth and grow commensurately with patients. They can vary broadly in vessel type and tissue involvement, and upper extremity (UE) VMs can pose unique functional and aesthetic challenges in children. Given the advent of operative and nonoperative technologies like sclerotherapy and medications, a contemporary review of the surgical management of UE VMs is warranted.

METHODS

We performed a retrospective review of all patients who had surgical management of VMs from 2010 to 2021 at The Children's Hospital of Philadelphia. Demographics, lesion characteristics, treatment (including preceding nonsurgical therapies), complications, and final outcomes were recorded. Operative notes were reviewed for date of operation, depth of excision, type of closure, and current procedural terminology code.

RESULTS

Sixty-seven patients with 88 procedures were studied. Average patient age was 5.8 years, with 64% White and 67% male. Venous (34%) and lymphatic (19%) malformations were most common, and anatomic locations were most frequently on the hand (33%) and forearm (25%). The average lesion diameter was 4.2 cm, although this varied by location (eg, 2.9 cm, hand; 11.1 cm, chest wall). Fifty-eight patients (87%) underwent surgical excision as their index procedure, and 9 had sclerotherapy before surgery. Thirty-nine patients (60%) had subcutaneous excisions, and the remainder required subfascial or intramuscular excisions. Nearly all excisions were closed primarily (97%). Of the 53 patients with documented follow-up, 32 patients (60%) had complete resolution of their lesion as of their final visit. Thirty of these 32 patients with no clinical evidence of residual VM had only 1 surgery for excision.

CONCLUSION

Upper extremity VMs were composed of diverse conditions with varying vessel types, size, depth, and anatomic sites. Surgical excision of VMs of the UE was safe and effective. A majority of VMs were fully excised after 1 procedure and frequently closed primarily with relatively low complication rates. Future work should investigate decision-making and outcomes of all treatment options of VMs of the UE for optimal functionality and aesthetics.

Differential Pacing Maneuver From the Vein of Marshall

BACKGROUND

Bidirectional mitral isthmus (MI) block is conventionally verified by differential pacing from the coronary sinus (CS) and its sequence change. This study aimed to evaluate the ability of differential pacing from the vein of Marshall (VOM) to detect epicardial MI connections.

METHODS

Radiofrequency and VOM ethanol MI ablation were performed with a VOM electrode catheter inserted to the septal side of the ablation line. MI block was verified using conventional CS pacing. To perform differential VOM pacing analysis, initial pacing was delivered from a distal VOM bipole closer to the block line, and then from a proximal VOM bipole. The intervals from pacing stimulus during different VOM pacing sites to the electrogram recorded through the CS catheter on the opposite side of the line were compared. When the interval during distal VOM pacing was longer than that during proximal VOM pacing, it indicated a VOM connection block; however, if the former interval was shorter, the connection through the VOM was considered persistent.

RESULTS

Overall, 50 patients were evaluated. According to CS pacing, MI ablation was incomplete in 9 patients, in whom the analysis indicated persistent VOM connection. Among 41 patients with complete MI block, confirmed by CS finding, in 30 (73%) patients, the interval during distal VOM pacing was longer than that during proximal VOM pacing by 11±5 ms. However, in 11 patients (27%) the former interval was revealed to be shorter than the latter by 16±8 ms, indicating residual VOM connection. Conduction time across the line was significantly shorter in 11 patients than in the other 30 (166±21 versus 197±36 ms; P<0.01). Ten successful reevaluated analyses after VOM ethanol and further radiofrequency ablation of the connection indicated VOM block achievement.

CONCLUSIONS

Differential VOM pacing maneuver reflects the VOM conduction status. This maneuver can uncover residual epicardial connections that are missing with CS pacing.

Investigator attitudes on equipoise and practice patterns in the BEST-CLI trial

OBJECTIVES

There has been significant variability in practice patterns and equipoise regarding treatment approach for chronic limb-threatening ischemia (CLTI). We aimed to assess treatment preferences of Best Endovascular vs Best Surgical Therapy in Patients with CLTI (BEST-CLI) investigators prior to and following the trial.

METHODS

An electronic 60-question survey was sent to 1180 BEST-CLI investigators in 2022, after trial conclusion and before announcement of results. Investigators' preferences were assessed across clinical scenarios for both open (OPEN) and endovascular (ENDO) revascularization strategies. Vascular surgeon (VS) surgical and ENDO preferences were compared with a 2010 survey administered to prospective investigators before trial funding.

RESULTS

For the 2022 survey, the response rate was 20.2% and was comprised of VSs (76.3%), interventional cardiologists (11.4%) and interventional radiologists (11.6%). The majority (72.6%) were in academic practice and 39.1% were in practice for >20 years. During initial CLTI work-up, 65.8%, 42.6%, and 55.9% of respondents always or usually ordered an arterial duplex, computed tomography angiography, and vein mapping, respectively. The most common practice distribution between ENDO and OPEN procedures was 70/30. Postoperatively, a majority reported performing routine duplex surveillance of vein bypass (99%), prosthetic bypass (81.9%), and ENDO interventions (86%). A minority reported always or usually using the wound, ischemia, and foot infection (WIfI) criteria (25.8%), GLASS (8.3%), and a risk calculator (14.8%). More than one-half (52.9%) agreed that the statement "no bridges are burned with an ENDO-first approach" was false. Intervention choice was influenced by availability of the operating room or ENDO suite, personal schedule, and personal skill set in 30.1%, 18.0%, and 45.9% of respondents, respectively. Most respondents reported routinely using paclitaxel-coated balloons (88.1%) and stents (67.5%); however, 73.3% altered practice when safety concerns were raised. Among surgeons, 17.8%, 2.9%, and 10.3% reported performing >10 annual alternative autogenous vein bypasses, composite vein composite vein bypasses, and bypasses to pedal targets, respectively. Among all interventionalists, 8%, 24%, and 8% reported performing >10 annual radial access procedures, pedal or tibial access procedures, and pedal loop revascularizations. The majority (89.1%) of respondents felt that CLTI teams improved care; however, only 23.2% had a defined team. The effectiveness of the teamwork at institutions was characterized as highly effective in 42.5%. When comparing responses by VSs to the 2010 survey, there were no changes in preferred treatment based on Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) II classification or conduit preference. In 2022, OPEN surgery was preferred more for a popliteal occlusion. For clinical scenarios, there were no differences except a decreased proportion of respondents who felt there was equipoise for major tissue loss for major tissue loss (43.8% vs 31.2%) and increased ENDO choice for minor tissue loss (17.6% vs 30.8%) (P < .05).

CONCLUSIONS

There is a wide range of practice patterns among vascular specialists treating CLTI. The majority of investigators in BEST-CLI had experience in both advanced OPEN and ENDO techniques and represent a real-world sample of technical expertise. Over the course of the decade of the BEST-CLI trial, there was overall similar equipoise among VSs.

Effectiveness of a native vein arteriovenous fistula tracking system

OBJECTIVE

This study aims to evaluate the effectiveness of a tracking program on the functional maturation rate of arteriovenous fistula (AVF).

METHODS

Two major clinical outcomes (commencement of cannulation and functional maturation) of created AVFs were compared between two cohorts. (i) Cohort 1: historical cohort; (ii) Cohort 2: AVFs created after implementation of the tracking project. Multivariable Cox regression models were used to assess the association between cohort allocation and the two major clinical outcomes.

RESULTS

Data of 114 and 141 patients were analyzed respectively from Cohorts 1 (historical data) and 2 (with AVF tracking). After adjustment of covariates in the multivariable analysis, the AVFs created in Cohort 2 were more likely to be cannulated earlier (adjusted HR: 2.82; 95% CI: 1.97-4.05; p < 0.001), compared to those in Cohort 1. Similarly, the AVFs of Cohort 2 patients had significantly higher probability of functional maturation (adjusted HR: 1.81; 95% CI: 1.31-2.48; p < 0.001) than fistulas in Cohort 1. Cannulation was commenced for half of the AVFs by 4.1 months post-creation in the historical cohort (Cohort 1), whereas in the post-tracking cohort, 50% of the AVFs were cannulated by 2.3 months after creation (p < 0.001). It took 5.5 and 4.3 months for 50% of the AVFs created in Cohort 1 and Cohort 2 patients to achieve catheter-free functional maturation, respectively (p = 0.06).

CONCLUSION

An AVF tracking program with maturation target for the access surgeons, together with a standardized tracking, feedback, and clinical strategy adjustment system is able to improve the AVF functional maturation rate.

Microvascular Decompression for Trigeminal Neuralgia Caused by Vascular Compression on the Trigeminal Sensory Nucleus and Descending Trigeminal Tract

BACKGROUND

Trigeminal neuralgia (TN) is characterized by paroxysmal episodes of severe shocklike orofacial pain typically resulting from arterial compression on the trigeminal root entry zone. However, neurovascular conflict in more proximal parts of the trigeminal pathway within the pons is extremely rare.

METHODS

The authors present a case of microvascular decompression for TN caused by dual arterial compression on the dorsolateral pons, along with a brief literature review.

RESULTS

Our patient was a 74-year-old man with episodic left-sided facial stabbing pain. Brain magnetic resonance imaging revealed a dual arterial compression on dorsolateral pons, the known site of the trigeminal sensory nucleus and descending trigeminal tract. Microvascular decompression was performed via a retrosigmoid approach. Complete pain relief and partial improvement of the facial hypesthesia were achieved immediately after surgery and the Barrow Neurological Institute (BNI) pain intensity score improved from V to I, and the BNI hypesthesia score decreased from III to II within a month following surgery. The literature review identified 1 case of TN secondary to an arteriovenous malformation in root entry zone with lateral pontine extension. One month following partial coagulation of the draining vein, the patient was reportedly able to reduce medication dosage by half to achieve an improvement of BNI pain intensity score from V to IIIa.

CONCLUSIONS

Neurovascular compression in the trigeminal tract and nucleus is a rare but potential cause of TN. A thorough investigation of the trigeminal pathway should be considered during preoperative evaluation and intraoperative inspection, particularly if no clear offending vessel is identified.

Outcomes of one-stage and two-stage aneurysm repair in arteriovenous fistulae

OBJECTIVE

Maintenance of long-term arteriovenous access is important in long-term care for patients with end-stage renal disease. Arteriovenous access is associated in the long term with the development of fistula aneurysms (FAs). This study aims to evaluate the outcomes of staged FA treatment in dialysis access arteriovenous fistulae (AVF).

METHODS

A retrospective review of all patients over a 12-year period with primary autogenous AVF was undertaken at a single center. Patients undergoing elective open aneurysm repair were identified and were categorized into three groups: single FA repair (single, control group) and staged and unstaged repair of two FAs (staged and unstaged). A staged repair was a procedure in which the initial intent was to treat both aneurysms in the AVF and in which the most symptomatic aneurysm was treated first. When the incision from the first surgery had healed, the second symptomatic aneurysm in the AVF was treated. An unstaged repair was a procedure in which the initial intent was to repair both symptomatic aneurysms simultaneously. All patients had a fistulogram before the FA repair. Thirty-day outcomes, cannulation failure, line placement, reintervention, and functional dialysis (continuous hemodialysis for 3 consecutive months) were examined.

RESULTS

Five hundred twenty-seven patients presented with FA that met requirements for open intervention; 44% underwent single FA repair, whereas the remaining 34% and 22% underwent staged and unstaged repair of two FAs, respectively. The majority of patients were diabetic and Hispanic. Ninety-one percent of the patients required percutaneous interventions of the outflow tract (37%) and the central veins (54%). Thirty-day major adverse cardiovascular events were equivalent across all modalities. Thirty-day morbidity and early thrombosis (<18 days) were significantly higher in the unstaged group (4.3%) compared with the two other groups (1.3% and 2.1%, single and staged, respectively), which led to an increased need for a short-term tunneled catheter (8.9%) compared with the two other groups (3.4% and 4.4%, single and staged, respectively), Unstaged repair resulted in an increased incidence of secondary procedures (5.0%) compared with the two other groups (2.6% and 3.1%, single and staged, respectively). Functional dialysis at 5 years was equivalent in the single and staged groups but was significantly decreased in the unstaged group.

CONCLUSIONS

Open interventions are successful therapeutic modalities for FAs, but unstaged rather than staged repair of two concurrent FAs results in a higher early thrombosis, an increased secondary intervention rate, and a need for a short-term tunneled central line. Staged and single FA repairs have equivalent results. In the setting of two symptomatic FAs, staged repair is recommended.

A Novel Vascular Anastomotic Coupling Device for End-to-End Anastomosis of Arteries and Veins

OBJECTIVE

Hand-sutured (HS) techniques remain the gold standard for most microvascular anastomoses in microsurgery. HS techniques can result in endothelial lacerations and back wall suturing, leading to complications such as thrombosis and free tissue loss. A novel force-interference-fit vascular coupling device (FIF-VCD) system can potentially reduce the need for HS and improve end-to-end anastomosis. This study aims to describe the development and testing of a novel FIF-VCD system for 1.5 to 4.0 mm outside diameter arteries and veins.

METHODS

Benchtop anastomoses were performed using porcine cadaver arteries and veins. Decoupling force and anastomotic leakage were tested under simulated worst-case intravital physiological conditions. The 1.5 mm FIF-VCD system was used to perform cadaver rat abdominal aorta anastomoses.

RESULTS

Benchtop testing showed that the vessels coupled with the FIF-VCD system could withstand simulated worst-case intravital physiological conditions with a 95% confidence interval for the average decoupling force safety factor of 8.2 ± 1.0 (5.2 ± 1.0 N) and a 95% confidence interval for the average leakage rate safety factor of 26 ± 3.6 (8.4 ± 0.14 and 95 ± 1.4 μL/s at 150 and 360 mmHg, respectively) when compared to HS anastomotic leakage rates (310 ± 14 and 2,100 ± 72 μL/s at 150 and 360 mmHg, respectively). The FIF-VCD system was successful in performing cadaver rat abdominal aorta anastomoses.

CONCLUSION

The FIF-VCD system can potentially replace HS in microsurgery, allowing the safe and effective connection of arteries and veins. Further studies are needed to confirm the clinical viability and effectiveness of the FIF-VCD system.

Characterizing Trends in Chronic Superficial Venous Disease Treatment among Medicare Beneficiaries from 2010 to 2018

This study describes trends in surgical versus endovascular interventions for treatment of chronic superficial venous disease (SVD) in the Medicare population. Medicare Part B data from 2010 to 2018 were obtained. Claims for SVD treatment were identified using Healthcare Common Procedure Coding System codes. Total percentage change in utilization rates and market share was determined for each provider group. Utilization of SVD treatments increased by 58%, mostly owing to growing utilization of endovascular treatments. There was a 66% decrease in surgical treatments. The utilization of ablation and sclerotherapy plateaued in 2016 and decreased in 2017-2018 with the advent of mechanochemical ablation, endovenous microfoam, and cyanoacrylate adhesive, respectively. Analysis showed that endovascular utilization increased across most specialties, with the largest growth seen in cardiology by 427%. Radiologists showed utilization growth of 125%, encompassing 11% of the market share. Endovascular treatment for SVD remains predominant, with increased utilization and concomitant decrease in surgical methods.

Anatomical features of a crossing vein connecting left and right internal mammary veins: A preliminary study with computerized tomography or magnetic resonance imaging

BACKGROUND

In breast reconstruction with free flaps, retrograde venous anastomosis into the internal mammary vein (IMV) is often unavoidable. Utility of a crossing vein between the right and left IMV, one of the anatomical foundations which make retrograde flow possible, has been reported but only with a few detailed features. This study evaluated the presence, actual location, and diameter of the crossing veins using preoperative imaging such as contrast-enhanced computed tomography (CECT), or contrast-enhanced magnetic resonance imaging (CEMRI). Moreover, this is a preliminary non-invasive study to clarify these processes on a larger scale.

METHODS

We included 29 cases of unilateral breast reconstruction performed between July 2018 and September 2023 at our institution using unipedicled or bipedicled free deep inferior epigastric artery perforator (DIEP) flaps with retrograde venous anastomosis to only one IMV at the level of anastomosis. No congestion or necrosis was observed. In the final 24 cases with sufficient imaging coverage of preoperative contrast-enhanced images (15 CECT and 9 CEMRI), the crossing veins of IMVs were detected and the number, localization, and diameter were measured.

RESULTS

In 20 cases of 24 images, the crossing veins between IMVs were completely identified (83%). In 18 of the cases, only one crossing vein was established immediately ventral to the xiphoid process, averaging 19.3 ± 7.18 mm caudal to the fibrous junction between the sternal body and xiphoid process. The average diameter of the veins was 1.57 ± 0.42 mm. In two other cases, the second crossing vein originated on the dorsal surface of the sternum, but it was a very thin vein of about 0.4 mm. Three images indicated incomplete identification of the crossing vein at the xiphoid process, and in one case, no crossing vein was observed between bilateral IMVs.

CONCLUSION

The contrast-enhanced imaging study revealed an anatomic feature that the crossing veins (about 1.5 mm in diameter) connecting the right and left IMVs are located just ventral to the xiphoid process. Furthermore, the crossing veins can be identified on contrast-enhanced images, and refinement of this method is expected to lead to future non-invasive anatomical investigations in an even larger number of cases.

Free tissue transfer using bidirectional recipient veins in traumatic extremity reconstruction

BACKGROUND

Reverse-flow flaps rely on retrograde or reverse flow for drainage and have shown success in reconstructive surgery. However, limited studies have been conducted on the use of reverse-flow recipient veins. Our study proposed bidirectional venous anastomoses within a single recipient vein to optimize venous outflow and evaluated the outcomes of an additional retrograde venous anastomosis group in traumatic extremity reconstruction.

METHODS

We performed a retrospective analysis of 188 patients with traumatic extremity free flap using two venous anastomoses, which were divided into the antegrade and bidirectional venous anastomosis groups. We analyzed the basic demographic information, flap type, duration between injury and reconstruction, recipient vessels, postoperative flap outcomes, and complications. Propensity score matching was used for the additional analysis.

RESULTS

Of the 188 patients analyzed, 63 free flaps (126 anastomoses, 33.5%) and 125 free flaps (250 anastomoses, 66.5%) were included in the bidirectional venous anastomosis and antegrade groups, respectively. In the bidirectional vein group, the median time between trauma and reconstruction was 13.0 ± 1.8 days and the mean flap area was 50.29 ± 7.38 cm2 . Radial artery superficial palmar branch perforator flap was most frequently performed (60.3%). In the antegrade vein group, the median time until surgery was 23.0 ± 2.1 days and the mean flap area was 85.0 ± 8.5 cm2 . Thoracodorsal artery perforator flap surgery was the most frequently performed surgery. The two groups were similar in terms of basic characteristics, but the bidirectional group demonstrated significantly higher success rate (98.4% vs. 89.7%, p = .004) and lower complication rate (6.3% vs. 22.4%, p = .007) than the antegrade group. However, these results were not observed after propensity score matching.

CONCLUSIONS

Our study demonstrated successful results with the recipient vein using reverse flow. Additional retrograde venous anastomosis is a useful option for augmenting venous drainage for reconstruction of distal extremities in cases where dissection of additional antegrade vein is not feasible.

Lymphovenous shunts in the treatment of lymphedema

Lymphedema is a progressive disease with no known cure. Characterized by the accumulation of lymphatic fluid and subsequent swelling in the affected limbs, it often poses significant challenges to those living with it. Although various conservative treatments have been used to manage lymphedema, such as compression therapy and physical rehabilitation, surgical interventions have emerged as promising avenues for more substantial relief. Lymphovenous shunts have been described since the 1960s and have garnered much attention in the recent two decades due to technological advances in optics, imaging, and surgical instruments. This review article explores the use of different lymphovenous shunts such as lymphatic implantation, lymph node-to-vein anastomoses (LNVAs), dermal-adipose lymphatic flap venous wrapping (DALF-VW), and supermicrosurgical lymphovenous anastomoses (LVAs) as treatment modalities for lymphedema. We will discuss the underlying principles, indications, techniques, and potential benefits. By examining the current state of knowledge and ongoing research in the field, we aim to provide insights into the role of lymphovenous shunts in the comprehensive management of lymphedema and shed light on the prospects for this treatment option.

Effect of exercises on the maturation of newly created arteriovenous fistulas over distal and proximal upper limb: A systematic review and meta-analysis

The aims of our review were: (i) to evaluate the effect of post-operative upper extremity exercise on maturation of AVFs, stratified by their locations. (ii) To evaluate the effect of pre-operative arm exercise on patients' superficial vein caliber of patients. Literature search was performed on PubMed, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and China National Knowledge Infrastructure (CNKI) to identify eligible articles. The quality of the randomized controlled trials (RCTs) were assessed using the Cochrane Risk of Bias tool 2.0. In the Meta-analysis, Risk ratios (RRs) of clinical maturation and ultrasonographic maturation were pooled from studies focused on post-operative exercise program; Mean difference (MD) of venous caliver was pooled from those studied pre-operative exercise. Nine studies (six for post-operative exercise; three for pre-operative exercise) were included in the review. Among the AVFs created in distal region (158 patients in exercise group and 144 patients in control group), there was a significantly superior clinical maturation (RR: 1.28; 95% CI: 1.10-1.48, p = 0.001; I2 = 0), and ultrasonographic maturation (RR: 1.30; 95% CI: 1.07-1.59, p = 0.009; I2 = 0) in the exercise group in comparison to the control group. For the AVFs created in proximal region (93 and 96 patients in exercise group and control group respectively), there is no significant difference in clinical maturation (RR:1.25, 95% CI: 0.88-1.78, p = 0.27, I2 = 74%) and ultrasonographic maturation (RR: 1.17, 95% CI: 0.97-1.40, p = 0.11, I2 = 43%) between the exercise group and controls. For pre-operative exercise, the mean difference of 0.34 mm (95% CI: 0.23-0.46, p < 0.001, I2 = 87% ) was found for vein size. In conclusion, existing upper extremity exercise programs appear to be useful in facilitating maturation of AVFs created in distal region, while its effect on fistulas created in proximal region is less certain. However, more robust trials are warranted to establish these findings.

Negative pressure wound therapy for prolonged surgical wound healing after brachiobasilic arteriovenous fistula creation in a patient with end-stage liver failure

A 54-year-old male patient diagnosed with hepatorenal syndrome caused by decompensated alcoholic cirrhosis was referred for arteriovenous fistula (AVF) creation after initiation of hemodialysis. A brachiobasilic arteriovenous fistula (BBAVF) was created because neither forearm had suitable vasculature. Large-volume serous effusion from the incision persisted postoperatively, and we started negative pressure wound therapy (NPWT) for wound protection. The effusion volume decreased gradually; however, up to 80 ml of discharge continued daily. Re-operation was performed 35 days after the initial operation, followed by continued NPWT. The wound was almost healed 85 days after the primary surgery. We present a case of severe surgical wound complication after AVF creation in a patient with hemostatic and coagulation disorders and malnutrition caused by end-stage hepatic failure. We confirmed the usefulness of NPWT for excessive surgical wound effusion and the adequacy of BBAVF for vascular access.

Overlapping lockup lymphaticovenous anastomosis: A useful addition to supermicrosurgery

BACKGROUND

Lymphaticovenular anastomosis (LVA) is a minimally invasive surgical procedure used to treat lymphedema. This surgical procedure connects the superficial lymphatic vessels to nearby veins to establish lymphatic-venous pathways. One of the most common challenges encountered by lymphatic surgeons when performing LVA is a mismatch in the sizes of the veins and lymphatic vessels, with the effectiveness limited by technical constraints. We conducted a pilot study to evaluate the feasibility of an overlapping lockup anastomosis (OLA) LVA technique to address these problems.

METHODS

In this study, we present a novel OLA technique for LVA that addresses the challenges with conventional techniques. The OLA technique was used in 10 lymphedema patients between September 2022 and March 2023 to compare OLA and end-to-end anastomosis. The time required for anastomosis, method of anastomosis, patency rates, and lymphedema volume were evaluated in this study.

RESULTS

Of 123 LVAs, 44 were performed using the OLA technique in 10 patients, with indocyanine green lymphangiography revealing unobstructed drainage. A single case of slight fluid leakage occurred, which was resolved by reinforcing the sutures. The average anastomosis time for OLA and the end-to-end technique was 5.55 minutes and 12.1 minutes, respectively. The wounds of the patients healed without infection, and the subjective limb circumference decreased.

CONCLUSIONS

The OLA technique could serve as a valuable addition to the current LVA technique, especially for cases with a mismatch in the sizes of the lymphatic vessels and veins. This technique has the potential to promote the broader application of LVA in the treatment and prevention of lymphedema.

Size adjustment suture technique for lymphaticovenular anastomosis

In this report, we describe a super microsurgical technique that enables rapid and accurate anastomosis while adjusting for caliber differences when anastomosing a small-caliber lymphatic vessel and a vein with a larger caliber, which is frequently encountered in surgeries such as lymphaticovenous anastomosis (LVA).  The suture size adjustment technique was performed in 30 anastomoses of lymphatic vessels and veins, whose diameter of lymph duct was at least two times smaller than that of the vein. The type of lymphedema, caliber of lymphatic vessels and veins anastomosed, caliber ratio, vein wall thickness, modified caliber ratio after vein wall thickness subtracted, presence of additional anastomosis, and anastomosis time were examined. On average, the lymphatic vessels had a diameter of 0.61 mm, while the veins were 1.43 mm in diameter. The mean caliber ratio of vein to lymphatic vessel was 2.3, while the modified caliber ratio of vein-to-lymphatic vessel was 1.5 on average. The average venous wall thickness was 0.51. The average anastomosis time was 9.1 min and no additional anastomosis due to leakage was necessary in any case. We successfully performed an anastomosis of lymphatic vessels and veins with different calibers, which can maintain long-term patency while adjusting the caliber difference and suppressing leakage at the anastomosis site. Finally, the caliber of the vein is commonly larger than that of the lymphatic vessel to be anastomosed in many cases of LVA surgery, indicating that the proposed anastomosis method could be of therapeutic use in many cases.

A systematic review of the scientific evidence of venous supercharging in autologous breast reconstruction with abdominally based flaps

BACKGROUND

Abdominally based free flaps are commonly used in breast reconstruction. A frequent complication is venous congestion, which might contribute to around 40% of flap failures. One way to deal with it is venous supercharging. The primary aim of this study was to investigate the scientific evidence for the effects of venous supercharging.

METHODS

A systematic literature search was conducted in PubMed, CINAHL, Embase, and Cochrane library. The included articles were critically appraised, and certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

RESULTS

Thirty-six studies were included. Most studies had serious study limitations and problems with directness. Three studies report 'routine' use of venous supercharging and performed it prophylactically in patients who did not have clinical signs of venous congestion. Seventeen studies report on flap complications, of which one is a randomised controlled trial demonstrating statistically significant lower complication rates in the intervention group. The overall certainty of evidence for the effect of a venous supercharging on flap complications, length of hospital stay and operative time, in patients without clinical signs of venous congestion, is very low (GRADE ⊕ ⊕ ⊝ ⊝), and low on and surgical takebacks (GRADE ⊕ ⊕ ⊝ ⊝). Twenty-one studies presented data on strategies and overall certainty of evidence for using radiological findings, preoperative measurements, and clinical risk factors to make decisions on venous supercharging is very low (GRADE ⊕ ⊝ ⊝ ⊝).

CONCLUSION

There is little scientific evidence for how to predict in which cases, without clinical signs of venous congestion, venous supercharging should be performed. The complication rate might be lower in patients in which a prophylactic venous anastomosis has been performed.

TRIAL REGISTRATION

PROSPERO (CRD42022353591).

The Deciding Factors of Flow Direction in Lymphovenous Anastomosis for Extremity Lymphedema

BACKGROUND

While using lymphovenous anastomosis (LVA) to treat extremity lymphedema, an antegrade lymphatic-to-venous flow is usually considered to indicate a functional and effective anastomosis. The authors analyzed the characteristics of lymphovenous anastomoses in patients with extremity lymphedema to look for the deciding factors of the flow direction.

METHODS

A total of 45 patients (15 arms and 42 legs) undergoing LVA for extremity lymphedema were reviewed. Only the anastomoses with intraoperatively confirmed patent flow or clear visualization of vessel lumens during anastomosis were included for analysis. Multivariate logistic regression was used to identify the contributing factors of intraoperative washout phenomenon or venous reflux.

RESULTS

A total of 105 eligible LVAs were included for analysis. Anastomosis with a more sclerotic lymphatic duct is statistically significantly associated with more venous reflux (OR, 2.82; P = 0.003). Larger diameter difference between lymphatic duct and recipient vein (OR, 12.8; P = 0.02) and less sclerotic lymphatic duct (OR, 0.47; P = 0.03) are statistically significantly associated with more washout phenomena.

CONCLUSIONS

The deciding factors of flow direction in LVA are difference of diameters between lymphatic duct and recipient vein, and the severity of lymphosclerosis. To obtain favorable antegrade lymph-to-vein flow, a less sclerotic lymphatic duct with larger diameter and a recipient vein with smaller diameter should be chosen for anastomosis.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

A snapshot of early venous remodeling in a 7-day-old arteriovenous fistula

Early remodeling of the arteriovenous fistula (AVF) determines maturation outcomes. However, the cellular response of the venous wall early after AVF creation remains largely enigmatic because of the lack of venous biopsies obtained shortly after anastomosis. This report presents a detailed immunohistochemistry analysis of a pre-access cephalic vein and the resulting seven-day-old AVF that required ligation due to steal syndrome. We test for markers of mature and progenitor endothelial cells (CD31, CD34, VWF), contractile smooth muscle cells and myofibroblasts (MYH11, SMA), and immune cell populations (CEACAM8, CD3, CD20, CD11b, CD45, CD68, CD163, tryptase). We demonstrated near complete endothelial coverage of the fistula at 7 days, a high degree of wall neovascularization, pronounced loss of myofibroblasts and smooth muscle cells, and significant infiltration of mast cells, neutrophils, monocytes, and macrophages. Of interest, the presence of CD163+ macrophages in the AVF suggests a reactive response to increased intramural oxygenation. In conclusion, these images provide for the first time a glimpse of early remodeling in a human AVF by immunohistochemistry. This case demonstrates the possibility to obtain additional precious samples of this early stage through future multicenter collaborative efforts.

Practice variation in venous resection during pancreatoduodenectomy for pancreatic cancer: A nationwide cohort study

BACKGROUND

Practice variation exists in venous resection during pancreatoduodenectomy, but little is known about the potential causes and consequences as large studies are lacking. This study explores the potential causes and consequences of practice variation in venous resection during pancreatoduodenectomy for pancreatic cancer in the Netherlands.

METHODS

This nationwide retrospective cohort study included patients undergoing pancreatoduodenectomy for pancreatic cancer in 18 centers from 2013 through 2017.

RESULTS

Among 1,311 patients undergoing pancreatoduodenectomy, 351 (27%) had a venous resection, and the overall median annual center volume of venous resection was 4. No association was found between the center volume of pancreatoduodenectomy and the rate of venous resections, nor between patient and tumor characteristics and the rate of venous resections per center. Female sex, lower body mass index, neoadjuvant therapy, venous involvement, and stenosis on imaging were predictive for venous resection. Adjusted for these factors, 3 centers performed significantly more, and 3 centers performed significantly fewer venous resections than expected. In patients with venous resection, significantly less major morbidity (22% vs 38%) and longer overall survival (median 16 vs 12 months) were observed in centers with an above-median annual volume of venous resections (>4).

CONCLUSION

Patient and tumor characteristics did not explain significant practice variation between centers in the Netherlands in venous resection during pancreatoduodenectomy for pancreatic cancer. The clinical outcomes of venous resection might be related to the volume of the procedure.

Microvascular anastomotic coupler for venous end-to-side anastomoses in head and neck reconstructive surgery

BACKGROUND

The use of coupler devices has become mainstream in microsurgical end-to-end venous anastomoses (EEA) for free flaps in head and neck reconstruction. Reports about end-to-side venous anastomoses (ESA) using a coupler are scarce, though.

METHODS

The surgical technique of end-to-side anastomosis using a coupler device is described. End-to-side anastomoses and end-to-end anastomoses with a vascular coupler are compared with respect to postoperative vascular complications.

RESULTS

124 patients were included, 76 with EEA, 48 with ESA. Postoperative venous complications occurred in 5.3% and 2.1%, respectively.

CONCLUSIONS

ESA is a valuable alternative to EEA when using a coupler device providing more flexibility to the surgeon.

Lymphaticovenous anastomosis for treatment of refractory chylous ascites: A case report

Chylous ascites, the leakage of lymphatic fluid into the abdominal cavity caused by lymphatic fluid stasis or lymphatic vessel damage, can be treated by lymphaticovenous anastomosis (LVA). We report rarely performed abdominal LVA to treat a case of refractory ascites possibly caused by ligation of the thoracic duct and pleurodesis in a man aged 60 years requiring weekly ascites drainage. Ligation was abandoned because the leakage site was not determined. The greater omentum (GO) was generally edematous and showed lymphatic effusion by gross appearance, and was considered suitable for LVA. We performed once LVA in the lymphatic vessels and veins of the GO using common microsurgical instrumentation and lateral anastomosis. Lymphatic vessels in the omentum were dilated to 2-3 mm, and LVA was simple. After LVA, GO edema improved. Postoperatively, the patient developed paralytic ileus, which improved within a few days, and the patient was discharged without any increase in ascites after starting to diet. One year post-surgery, there was no recurrence of ascites. LVA at the GO may be effective for the treatment of refractory chylous ascites because of its absorptive lymphatic draining capabilities and large transverse vessels.

Early clinical experience and comparison between percutaneous and surgical arteriovenous fistula

BACKGROUND

Percutaneous arteriovenous fistula (pAVF) has been recently developed as an alternative to surgical AVF (sAVF). We report our experience with pAVF in comparison with a contemporaneous sAVF group.

METHODS

Charts of all 51 patients with pAVF performed at our institution were analyzed retrospectively, in addition to 51 randomly selected contemporaneous patients with sAVF (2018-2022) with available follow-up. Outcomes of interest were (i) procedural success rate, (ii) number of maturation procedures required, (iii) fistula maturation rates, and (iv) rates of tunneled dialysis catheter (TDC) removal. For patients on hemodialysis (HD), sAVF and pAVF were considered mature when the AVF was used for HD. For patients not on HD, pAVF were considered mature if flow rates of ≥500 mL/min were documented in superficial venous outflow; for sAVF, documentation of maturity based on clinical criteria was required.

RESULTS

Compared patients with sAVF, patients with pAVF were more likely to be male (78% vs 57%; P = .033) and less likely to have congestive heart failure (10% vs 43%; P < .001) and coronary artery disease (18% vs 43%; P = .009). Procedural success was achieved in 50 patients with pAVF (98%). Fistula angioplasties (60% vs 29%; P = .002) and ligation (24% vs 2%; P = .001) or embolization (22% vs 2%; P = .002) of competing outflow veins were more frequently performed on patients with pAVF. The surgical cohort had more planned transpositions (39% vs 6%; P < .001). When all maturation interventions were combined, pAVF required more maturation procedures, but this was not statistically significant (76% vs 53%; P = .692). When planned second-stage transpositions were excluded, pAVF had a statistically significant higher rate of maturation procedures (74% vs 24%; P < .001). Overall, 36 pAVF (72%) and 29 sAVF (57%) developed mature fistulas. This difference, however, was not statistically significant (P = .112). At the time of AVF creation, 26 patients with pAVF and 40 patients with sAVF were on HD, all through use of a TDC. Catheter removal was recorded in 15 patients with pAVF (58%) and 18 patients with sAVF (45%) (P = .314). The mean time until TDC removal in pAVF group was 146 ± 74 days, compared with 175 ± 99 in the sAVF group (P = .341).

CONCLUSIONS

Compared with sAVF, rates of maturation after pAVF seem to be similar, but this result may be related to the higher intensity of maturation procedures and patient selection. An analysis of appropriately matched patients will assist in elucidating the possible role of pAVF vis-a-vis sAVF.

Surgical and endovascular treatment of pelvic venous disorder: Results of a multicentre retrospective cohort study

OBJECTIVE

In the present study, we investigated the clinical outcomes after gonadal vein resection (GVR) and gonadal vein embolization (GVE) with coils in patients with pelvic venous disorder (PeVD). We also assessed the rates of procedural complications and disease recurrence.

METHODS

Our multicenter retrospective cohort study included 361 female patients with PeVD-related chronic pelvic pain (CPP) and gonadal vein reflux who underwent GVR (n = 184) or GVE with coils (n = 177) from 1999 to 2020. The clinical outcomes (ie, presence and severity of CPP, procedural complications, disease recurrence) were assessed at 1 month and 1, 3, and 5 years after intervention. The pain intensity before and after treatment was assessed using a visual analog scale. All the patients underwent duplex ultrasound after GVR and GVE, and those with persistent CPP and suspected perforation of the gonadal vein by the coils were also evaluated by multiplanar pelvic venography.

RESULTS

GVR and GVE was associated with the reduction or elimination of CPP at 1 month after treatment in 100% and 74% of patients and postprocedural complications in 14% and 37% of patients, respectively (Р < 0.01 for both). The most common complication after either GVR or GVE was pelvic vein thrombosis (11% and 22% patients, respectively; P < .01 between groups). GVE was associated with postembolization syndrome in 20%, coil protrusion in 6%, and coil migration in 1% of patients. The long-term recurrence rate after GVR and GVE was 6% and 16%, respectively (P < .01).

CONCLUSIONS

Both GVR and GVE were found to be effective in treating patients with PeVD. However, GVR was associated with better efficacy in the relief of CPP and lower rates of procedural complications and disease recurrence.

Use of chronically occluded fistula to establish access outflow

Maintaining a good quality vascular access in the long term can become particularly challenging especially in patients that are on dialysis for many years and present with exhausted venous capital and chronic access related complications. We present a 60-year-old female patient with multiple bilateral previous failed accesses, a previous distal revascularization interval ligation (DRIL) for hemodialysis access induced distal ischemia (HAIDI). Her chronically (more than a month) occluded arteriovenous fistula AVF was used to establish outflow and create a functioning forearm arteriovenous graft (AVG).

Superficialization of dilated radial artery for vascular access: A case report

Successful hemodialysis treatment need a well functioning vascular access (VA) allowing two cannulation sites with enough blood flow have minimum adverse events. The expectations, age of the HD population are rising as well as the lack of conventional methods due to central venous exhaustion, we have to choose some complex access, including complex or tertiary vascular access mentioned in 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS) and the option to abandon the venous circuit in instead of arterial system, including arterial-arterial graft and arterial superficialization. This article report a complicated case of AVF dysfunction, central venous stenosis due to central venous catheter and aortic dissection stent as well as lower extremity arteriosclerosis occlusion, using the simple method of superficialization of enlarged radial artery to maintain hemodialysis.

Outcome after surgical treatment of venous malformations of the hand in childhood

OBJECTIVE

Surgical treatment of venous malformations (VMs) of the hand is challenging. The hand's small functional units, dense innervation, and terminal vasculature can be easily compromised during invasive interventions like surgery or sclerotherapy, leading to an increased risk of functional impairment, cosmetic consequences, and negative psychological effects.

METHODS

We have conducted a retrospective review of all surgically treated patients diagnosed with VMs of the hand between 2000 and 2019 and evaluated their symptoms, diagnostic investigations, complications, and recurrences.

RESULTS

Twenty-nine patients (females, n = 15) with a median age of 9.9 years (range, 0.6-18 years) were included. Eleven patients presented with VMs involving at least one of the fingers. In 16 patients, the palm and/or dorsum of the hand was affected. Two children presented with multifocal lesions. All patients presented with swelling. Preoperative imaging was done in 26 patients and consisted of magnetic resonance imaging in nine patients, ultrasound in eight patients, and both modalities in nine patients. Three patients underwent surgical resection of the lesions without any imaging. Indications for surgery were pain and restriction of function (n = 16), and when lesions were preoperatively evaluated as completely resectable (n = 11). In 17 patients, a complete surgical resection of the VMs was performed, whereas in 12 children, an incomplete resection of VM was deemed due to nerve sheath infiltration. At a median follow-up of 135 months (interquartile range, 136.5 months; range, 36-253 months), recurrence occurred in 11 patients (37.9%) after a median time of 22 months (range, 2-36 months). Eight patients (27.6%) were reoperated because of pain, whereas three patients were treated conservatively. The rate of recurrences did not significantly differ between patients presenting with (n = 7 of 12) or without (n = 4 of 17) local nerve infiltration (P = .119). All surgically treated patients who were diagnosed without preoperative imaging developed a relapse.

CONCLUSIONS

VMs in the region of the hand are difficult to treat, and surgery is associated with a high recurrence rate. Accurate diagnostic imaging and meticulous surgery may contribute to improve the outcome of the patients.

Circumferential Radical Debridement and Omental Free Flap in the Treatment of Severe Chronic Venous Ulcers

BACKGROUND

Chronic venous leg ulcers are a significant health care burden with a difficult and unreliable treatment. Free flaps may be needed for wound coverage in severe cases. Incomplete removal of dermatoliposclerosis (DLS) area and/or not addressing the underlying venous dysfunction may contribute to the reported modest long-term results.

METHODS

A series of 5 patients with severe chronic venous ulcers of the leg, resistant to conservative treatment and superficial venous surgery, were treated with radical, circumferential, subfascial resection of the DLS skin and coverage with omental free flaps. Delayed arteriovenous (AV) loops were used as recipients. All patients had previous superficial venous surgery and multiple skin grafts. Mean follow-up was 8 years (4-15 years).

RESULTS

One hundred percent of flaps survived completely. No major complications occurred. One patient developed ulceration of the flap at 2 years and healed with basic wound care. At a mean follow-up of 8 years, all patients were ulcer-free. One patient died 15 years after the surgery for unrelated causes.

CONCLUSIONS

Radical circumferential resection of DLS area in severe chronic venous leg ulcers and coverage with a free omental flap using staged AV loop provided durable coverage in a series of 5 patients. Complete resection of DLS area, addressing the underlying venous pathology, and draining the flap to a healthy competent vein graft (AV loop) may contribute to these favorable results.

Patency Rates and Outcomes of Renal Access Arteriovenous Fistulas for Hemodialysis in Patients with Chronic Kidney Disease

Hemodialysis remains the most popular modality of renal replacement therapy for end-stage renal disease patients with chronic kidney disease. Various factors such as a radial artery, cephalic vein diameter, age, hypertension, and diabetes mellitus can affect the fistula maturation. This study was carried out to know the patency rates and factors affecting fistula maturation in the Indian population. This is a prospective observational study which aimed to study the patency rate of arteriovenous (AV) fistulas. On the day of surgery, patients were shifted inside the operation theater. Under all aseptic precautions, an AV fistula was formed using the radial artery and cephalic vein. All patients were followed up for 6 months. The data were analyzed using IBM SPSS version 22. To see the change over a period of time, McNemar test for categorical data and repeated measure for continuous data followed by post hoc comparison by Bonferroni method were used. The mean age of the patients was 46.98 ± 13.33 years. The mean diameter of the cephalic vein, ulnar artery, and radial artery at the wrist was 1.733 ± 0.528, 1.700 ± 0.364, and 1.908 ± 0.420, respectively, whereas the mean diameter of the cephalic vein, ulnar artery, and radial artery at the forearm was 1.952 ± 0.488, 1.910 ± 0.421, and 2.058 ± 0.458, respectively. Immediate thrill after the surgery was present in 36/52 (69.2%) of the patients. The radial artery diameter at the wrist was significantly less in the patients with primary failure in whom immediate thrill was not present (P = 0.016). At 1-month follow-up, 30/49 (61.2%) and, at 6 months, 29/48 (60.4%) fistulas were functional. Radiocephalic AV fistulas have a reasonable success rate and minimal morbidity, and radial artery diameter is a good predictor of the outcome.

Resectable fusiform internal jugular vein aneurysm with vascular excision and bypass with an 8 mm Maquet graft: A case report

RATIONALE

Venous aneurysm is a rare vascular disease. Studies reveal that patients with fusiform internal jugular vein aneurysms are not suitable for embolization.

PATIENT CONCERNS

Two treatment options are considered, either bypass the aneurysm via stenting or excision of the lesion site and anastomosis using an artificial graft. The advantages of excision bypass include the absence of endoleak and stent migration; however, a larger wound and longer operation time are required for it.

DIAGNOSES

Physical examination revealed a swelling in the right neck area. Head and neck computed tomography was performed for the survey. It revealed a 27.22 × 25.07 × 58.17 mm internal jugular fusiform aneurysm.

INTERVENTIONS

Vein excision was performed while using hemoclamps to control inflow and outflow, and a graft was anastomosed for bypass using an 8 mm Maquet graft.

OUTCOMES

The wound recovery was favorable, with no signs of infection, and the pain was under control.

LESSONS

The patient had a contrast-enhanced head and neck computed tomography, and the images efficiently diagnosed a venous aneurysm. This patient had refractory pain, which was a significant indication of the operation. We decided by ourselves on the duration of the interval of following up. We used excision and bypassing with graft, and the result was beneficial.

[Efficiency and safety of microsurgical cluster ligation of the spermatic vein]

OBJECTIVE

To study the effect and safety of microscopic varicocele cluster ligation (MVCL).

METHODS

We selected 28 patients undergoing bilateral microscopic spermatic vein ligation in Xuzhou Central Hospital from July 2021 to June 2022. Using the computerized randomization method, we performed MVCL or microscopic varicocele ligation (MVL) for the right or the left spermatic cord, respectively. We recorded the operation time, intraoperative blood loss, the numbers of the spermatic veins ligated and the arteries and lymphatic vessels preserved in each surgical side. A surgeon unaware of the surgical approach on the operative side collected the Visual Analogue Scale (VAS) pain scores, nodular foreign body sensation, relief of scrotal cramps, complications, and long-term recurrence from the patients.

RESULTS

Compared with the MVL group, the MVCL group showed significantly shorter time for spermatic vein ligation (［56.21±13.96］ vs ［31.43±10.13］ min, P<0.01), lower VAS scores on the 1st postoperative day (P <0.05) and a lower incidence of intra-scrotal nodular foreign body sensation in the 1st postoperative month (P <0.05). There were no statistically significant differences in the intraoperative blood loss, numbers of spermatic veins ligated and arteries and lymphatic vessels preserved, VAS scores at 3 and 7 postoperative days, incidence of complications and long-term recurrence between the two groups (P >0.05).

CONCLUSION

MVCL is superior to MVL in reducing the time of spermatic vein ligation and improving the efficiency, efficacy and safety of the procedure, and therefore worthy of clinical promotion.

Transcatheter Arterialization of Deep Veins in Chronic Limb-Threatening Ischemia

BACKGROUND

Approximately 20% of patients with chronic limb-threatening ischemia have no revascularization options, leading to above-ankle amputation. Transcatheter arterialization of the deep veins is a percutaneous approach that creates an artery-to-vein connection for delivery of oxygenated blood by means of the venous system to the ischemic foot to prevent amputation.

METHODS

We conducted a prospective, single-group, multicenter study to evaluate the effect of transcatheter arterialization of the deep veins in patients with nonhealing ulcers and no surgical or endovascular revascularization treatment options. The composite primary end point was amputation-free survival (defined as freedom from above-ankle amputation or death from any cause) at 6 months, as compared with a performance goal of 54%. Secondary end points included limb salvage, wound healing, and technical success of the procedure.

RESULTS

We enrolled 105 patients who had chronic limb-threatening ischemia and were of a median age of 70 years (interquartile range, 38 to 89). Of the patients enrolled, 33 (31.4%) were women and 45 (42.8%) were Black, Hispanic, or Latino. Transcatheter arterialization of the deep veins was performed successfully in 104 patients (99.0%). At 6 months, 66.1% of the patients had amputation-free survival. According to Bayesian analysis, the posterior probability that amputation-free survival at 6 months exceeded a performance goal of 54% was 0.993, which exceeded the prespecified threshold of 0.977. Limb salvage (avoidance of above-ankle amputation) was attained in 67 patients (76.0% by Kaplan-Meier analysis). Wounds were completely healed in 16 of 63 patients (25%) and were in the process of healing in 32 of 63 patients (51%). No unanticipated device-related adverse events were reported.

CONCLUSIONS

We found that transcatheter arterialization of the deep veins was safe and could be performed successfully in patients with chronic limb-threatening ischemia and no conventional surgical or endovascular revascularization treatment options. (Funded by LimFlow; PROMISE II study ClinicalTrials.gov number, NCT03970538.).