This study aimed at developing scores predicting surgical complications in obese transplant recipients, based on preoperative computed tomography (CT) parameters. All consecutive patients with a body ...mass index (BMI) ≥ 30 kg/m
who underwent kidney transplantation between 2012 and 2019 were included. The preoperative CT parameters were assessed: total fatty surface (TFS), subcutaneous fatty surface (SFS), iliac vessel to skin distance (VSD), and abdominal perimeter (AP). Per- and postoperative complications (vascular, urinary, parietal, and digestive complications) within 30 days were listed. Predictive models of surgical complications were generated based on the results of the logistic regression. Among the 163 patients included, 53 (32.5%) experienced surgical complications. The AP was a risk factor for complications in multivariate analysis (OR: 1.050; 95% CI: 1.016-1.087; p = 0.03). Two predictive models of complications were created based on the statistical analysis: a one-variable model based on AP (sensitivity 86.8%, specificity 41.8%, area under the curve (AUC) 65.3, with a cutoff value of 107 cm) and a five-variable model based on BMI, TFS, SFS, VSD, and AP (sensitivity 73.6%, specificity 57.3%, AUC 66.2). These models, based on patient morphometric measurements, could allow predicting the occurrence of surgical complications in obese candidates for kidney transplantation.
To evaluate the outcomes of robot assisted laparoscopic surgery for median arcuate ligament syndrome (MALS) relief.
This was a single centre and retrospective study, including all consecutive ...patients with symptomatic MALS treated with robot assisted laparoscopic surgery. Symptom relief and quality of life (QoL) were evaluated post-operatively. A comparison between the peak systolic velocity (PSV) of the coeliac artery (CA) measured pre-operatively and post-operatively was carried out.
Nine interventions were performed. No conversion to laparotomy was required. There was post-operative abdominal pain relief in eight patients and QoL was improved in seven patients. Post-operatively, the CA PSV decreased (175 (IQR 160 - 195) cm/s vs. 365 (IQR 350 - 419) cm/s; p < .001).
MALS relief with robot assisted laparoscopy is safe and provides satisfactory outcomes in terms of symptom relief and CA compression release.
•Robot assisted laparoscopy for median arcuate ligament syndrome is safe.•Coeliac artery release provides satisfactory outcomes in terms of symptoms relief.•Post-operatively, the coeliac artery peak systolic velocity significantly decreased.•Quality of life was improved in the majority of cases after surgery.
Arteriovenous malformations (AVMs) are rare, especially in elderly patients. Occasionally, AVM can produce aneurysmal degenerations, which can lead to bleeding or rupture. The aim of this case report ...was to describe the surgical treatment of large arterial and venous aneurysms in the arm associated with an AVM.
An 83 year old woman of White ethnicity who was a non-smoker presented with a large pulsatile aneurysm at the left elbow with paresis of the first three fingers. The diagnosis was made by duplex ultrasonography (DUS), computed tomography angiography (CTA), and arteriography. Additional tests confirmed aneurysms of the brachial artery and the outflow veins, with the largest more than 7 cm in diameter. A very proximal brachial artery bifurcation and increased venous flow were noted. DUS confirmed the AVM by showing continuous flow in the axillary vein. The decision for surgical resection involved vascular surgeons, radiologists, angiologists, and anaesthetists. Treatment involved opening and excision of multiple venous aneurysms and AVMs. A short segment of the aneurysmal brachial artery was also resected and repaired with end to end anastomosis. The deep brachial artery which supplied AVMs and venous aneurysms was ligated and excision of these lesions was performed. At one year follow up, there were no complications and the revascularisation was patent.
Arterial and venous aneurysms occurring together with AVMs are rare and not well documented in the medical literature. In this case, surgical intervention, including resection with direct anastomosis of the arterial aneurysm coupled with excision of venous aneurysms and AVM, proved to be effective, as evidenced by stable post-operative outcomes after one year.
•The surgical management of a rare case of arterial and venous aneurysms with AVM is presented.•The diagnosis was assessed by duplex ultrasonography, computed tomography angiography and arteriography.•The decision for surgical resection involved a multidisciplinary team.•The treatment is challenging and can be surgical, endovascular, or hybrid.
Calcification of a vascular endograft and adjacent tissues (adventitia, media, and neointima) can result in graft failure. This report shows a rare case of intraluminal calcifications in the distal ...end of a thoracic endovascular aortic repair (TEVAR) endograft implanted 11 years previously for grade IV blunt traumatic aortic injury (BTAI) in a young patient.
A 24 year old man required TEVAR for a BTAI caused by a motorcycle accident. The procedure consisted of TEVAR and an emergency left carotid subclavian venous bypass. Eleven years after the procedure, he had severe hypertension. Intra-TEVAR calcifications appeared, gradually increasing on computed tomography angiography (CTA). Calcifications in the distal luminal end of the TEVAR were responsible for a 60% stenosis on CTA. An open approach was indicated after multidisciplinary discussion, based on the gradient value. The patient underwent explantation, with total replacement of the aortic arch and descending thoracic aorta with re-implantation of the supra-aortic vessels, under extracorporeal circulation. Macroscopic analysis showed no device degeneration but revealed a solid mass at the distal end of the TEVAR. Both microcomputed tomography and histopathology confirmed the calcific nature of the lesions.
This case highlights a rare long term graft failure due to calcified neo-atherosclerosis in a TEVAR.
•Intra-TEVAR calcifications appeared 11 years after blunt traumatic aortic injury.•Neo-atherosclerosis can appear after TEVAR and lead to long term graft failure.•TEVAR neo-atherosclerosis, caused arterial hypertension, led to TEVAR explantation.
Objective Defective mitochondrial function has been reported in patients presenting with peripheral arterial disease, suggesting it might be an important underlying mechanism responsible for ...increased morbidity and mortality. We therefore determined the effects of prolonged ischemia on energetic skeletal muscle and investigated whether ischemic preconditioning might improve impaired electron transport chain and oxidative phosphorylation in ischemic skeletal muscle. Methods Thirty rats were divided in three groups: the control group (sham, n = 9) underwent 5 hours of general anesthesia without any ischemia, the ischemia–reperfusion (IR) group (n = 11) underwent 5 hours ischemia induced by a rubber band tourniquet applied on the left root of the hind limb, and in the third group, preconditioning (PC group, n = 10) was performed just before IR and consisted of three cycles of 10 minutes of ischemia, followed by 10 minutes reperfusion. Maximal oxidative capacities (Vmax ) of the gastrocnemius muscle and complexes I, II, and IV of the mitochondrial respiratory chain were determined using glutamate-malate (Vmax ), succinate (Vs ), and N, N, N,′N′-tetramethyl-p-phenylenediamine dihydrochloride ascorbate as substrates. Results Physiologic characteristics were similar in the three groups. Ischemia reduced Vmax by 43% (4.5 ± 0.4 vs 7.9 ± 0.5 μmol O2 /(min · g dry weight), P < .01) and Vs by 55% (2.9 ± 0.3 vs 6.3 ± 0.4 μmol O2 /min/g dry weight; P < .01) in the IR and sham groups, respectively, and impairments of mitochondrial complexes I and II activities were evident. Of interest was that preconditioning prevented ischemia-induced mitochondrial dysfunction. Both Vmax and Vs were significantly higher in the PC rats than in IR rats (+32% and +41%, respectively; P < .05), and were not different from sham values. Conclusions Ischemic preconditioning counteracted ischemia-induced impairments of mitochondrial complexes I and II. These data support that ischemic preconditioning might be an interesting approach to reduce muscular injuries in the setting of ischemic vascular diseases.
Use of the forearm basilic vein for the creation of an arteriovenous fistula has been codified as second-choice vascular access for hemodialysis in the last clinical guidelines of the Society for ...Vascular Surgery in 2008. Poor literature data on this technical option and on its evaluation and outcomes led us to initiate a retrospective single-center study.
We analyzed the outcomes of every arteriovenous fistula using the forearm basilic vein created in our department. It is a retrospective study in which we collected data prospectively by contacting dialysis centers, nephrologists, and patients. Primary end point was primary patency rate at 1 year. Secondary end points were secondary patency rate at 1 year, time of maturation, and Doppler flow measurement before the first puncture.
From February 2004 to June 2014, 49 forearm basilic arteriovenous fistulas were created: 33 ulnar-basilic and 16 radial basilic arteriovenous fistulas. Initial technical success rate was 98%. Functional success rate was 60%. Primary and secondary patency rates at 1 year were respectively 21% and 48%. Median time of maturation was 81 days, and mean Doppler flow measurement was 678 mL/min. Ulnar-basilic fistulas had a statistically significant shorter time of maturation than radial basilic fistulas (P ≤ 0.05).
Despite poor primary patency rate and a long time of maturation, forearm basilic arteriovenous fistula has satisfactory secondary patency rate and keeps all the advantages of a distal-located vascular access concerning complications. It is worth its second-choice place in the current algorithm of creation of vascular access for hemodialysis.
With the steady increase of endovascular procedures involving the aortic arch (AA), an actual depiction of its anatomy has become mandatory. It has also become necessary to evaluate the natural ...evolution of the AA morphology as part of the evaluation of endovascular devices durability. The objective of this study was to perform a morphological and anatomical study of the AA and of the supra aortic trunks (SAT) in healthy patients, with an evaluation of their evolution with time, with a specific orientation applied to endovascular therapies of the AA.
Sixty-one patients (31 men, mean age 50.8 18-82) with a normal anatomy were included in the study. Measurements included the diameters of the AA and SAT in 17 locations, their distance and angulation based on computed tomography angiography data. Statistical analysis focused on descriptive statistics, differences between genders, as well as correlations with age.
Aortic diameters (mean ± SD) were 29.5 ± 3.9 mm at the ascending aorta, 28.6 ± 3.9 mm at the innominate artery (IA), 27.1 ± 3.2 mm at the left common carotid artery (LCCA), 25.3 ± 3.0 mm at the left subclavian artery (LSCA), 23.9 ± 3.3 mm at the descending aorta. Mean angulation of the AA was 82° (95% confidence interval CI: 78.95-85.19°), mean angulation between LSCA/LCCA was -5.7° (95% CI: -0.9 to 18.7°) and -1.8° (95% CI: 5.4-26.4°) between LCCA/IA. Mean distance between the LSCA and the LCCA was 14.3 mm (95% CI: 13-15.6 mm) and 21.8 mm (95% CI: 20.3-23.4 mm) between LCCA and IA. All diameters of the AA increased with age (P < 0.05). Men had diameters statistically (P < 0.05) greater than women except at the LCCA ostium level. A statistically significant increase of the distances between the LSCA and the LCCA, between the LSCA and the IA and between the IA and the LCCA was found with age, P = 0.027, <0.01 and 0.012 respectively.
This study allows obtaining accurate information of the AA and the SAT anatomy. It enabled to obtain a better understanding of the three-dimensional aspects of the AA, confirmed the variability and heterogeneity of the SAT disposition, and discussed the principles of vascular aging.
The objective of the present study was to evaluate the bioresorption rate of collagen coating (CC) sealed on textile vascular grafts (VGs) and their healing in humans using histologic analysis of ...explanted VGs.
A total of 27 polyester textile VGs had been removed during surgery from 2012 to 2020. The segments underwent histologic assessment. The CC bioresorption rate was assessed using morphometric analysis to determine the internal and external capsule thickness, inflammatory reaction degree, presence of neovessels, and endothelial cell layer.
A total of 27 VGs were explanted from 25 patients because of infection (n = 5; 18.5%), thrombosis (n = 7; 25.9%), stenosis (n = 2; 7.4%), rupture (n = 4; 14.8%), aneurysmal degeneration (n = 3; 11.1%), revascularization (n = 4; 14.8%), or another cause (n = 2; 7.4%), with a median implantation duration of 291 days (interquartile range IQR, 48-911 days). VGs with remaining CC (n = 7; 26%) had been explanted earlier than had those without (n = 20; 74%; 1 day IQR, 1-45 days vs 516 days IQR, 79-2018 days; P = .001). After 1 year, no remaining CC was detected on the analyzed VG sections. VGs implanted for <90 days had had a greater CC maximal thickness (63.90 μm IQR, 0-83.25 μm vs 0 μm IQR, 0-0 μm; P = .006) and a greater CC surface coverage (180° IQR, 0°-360° vs 0° IQR, 0°-0°; P = .002) than those implanted for >90 days. VGs implanted for >90 days had a greater external capsule thickness (889.2 μm IQR, 39.6-1317 μm vs 0 μm IQR, 0-0 μm; P = .002), a higher number of inflammatory mononuclear cells and giant cells (168 cells IQR, 110-310 cells vs 0 cells IQR, 0-94 cells; P < .0001) and a higher number of neovessels (4 IQR, 0-5 vs 0 IQR, 0-0; P = .001) than those implanted for <90 days.
CC had a slow bioresorption rate in humans. Complete healing was never achieved, with no endothelial coverage observed. This finding implies that CC might not help graft healing.
The objective of the present study was to evaluate the bioresorption rate of collagen coating (CC) sealed on explanted textile vascular grafts (VGs) and their healing in humans using histologic analyses. We found that CC had a slow bioresorption rate in humans. Complete healing was never achieved, and no endothelial coverage was observed. Therefore, we question their use in daily practice because the faster healing potential of CC VGs has been an argument advanced by manufacturers for their use. Knowledge of the mechanisms of graft healing is necessary to understand the success and failure of the current bypass grafts.
Achieving aortic anastomosis in laparoscopic surgery remains a technical challenge. The Da Vinci robot could theoretically counteract this issue by minimizing the technical challenge. The aim of this ...study was to compare the learning curves of performing vascular anastomoses by trainees without any experience using purely laparoscopic versus robotic-assisted techniques.
Surgery residents were randomly included in the laparoscopic group (group A, n = 3) and the robotic group (group B, n = 3). They performed 10 end-to-end anastomoses on 18-mm-diameter tubular expanded polytetrafluoroethylene grafts. The parameters recorded were duration to complete the anastomosis and an indirect sealing quality evaluation (ISQE) defined as the following ratio: number of stitches with a distance of less than 4 mm/total number of stitches.
The mean duration to perform the anastomosis decreased from 2340 s (±64) for the first anastomosis to 651 s (±248) for the last in group A (P < 0.05) and from 1989 s (±556) to 801 s (±120) in group B (P < 0.05). The mean ISQE increased from 74% (±18) for the first anastomosis to 98% (±3) for the last in group A (P < 0.05) and decreased from 100% to 98% (±2) in group B (nonsignificant). The mean duration to perform the first anastomosis was lower in group B than in group A (P < 0.05). The mean duration to perform the last anastomosis was not significantly different between the groups. Sealing tended to be better in group B for the first anastomosis compared with group A.
Minimally invasive laparoscopic technique training demonstrates a learning curve to perform vascular anastomoses. The robotic-assisted technique tended to improve suturing skills and should be considered as a valuable tool to reduce the technical learning curve.
AbstractObjectiveInternal iliac artery (IIA) preservation is associated with improved outcomes after both open and endovascular aortoiliac aneurysm repair. Total robotic laparoscopic repair of ...aortoiliac aneurysms has been reported in the past, but not in combination with sutureless anastomosis applied to the IIAs. The objective of this study was to demonstrate the feasibility of the total robotic laparoscopic technique including a method of deploying the Gore Hybrid Vascular Graft (GHVG; W. L. Gore & Associates, Flagstaff, Ariz) using robotic instruments. MethodsBetween June 2015 and December 2016, four patients underwent total robotic laparoscopic repair of isolated common iliac artery (CIA) aneurysms. Two patients had unilateral aneurysms and two had bilateral aneurysms. Unilateral CIA aneurysms were treated with a graft from the proximal CIA to the proximal external iliac artery, and bilateral CIA aneurysms were treated with a bifurcated graft between the distal aorta and both proximal external iliac arteries. The nitinol reinforced section of the GHVG was then inserted and deployed into the corresponding IIA, and the nonreinforced segment was sewn in an end-to-side fashion to the iliac graft. ResultsThe median age of patients was 55.5 years (range, 48-64 years); median body mass index was 24.9 kg/m 2 (range, 23-26.4 kg/m 2). All four cases were technically successful. Operative times were 325 and 332 minutes for unilateral cases and 491 and 385 minutes for bilateral cases. For the entire series, median proximal clamping time was 143 minutes (range, 110-163 minutes), and the median time to deploy the GHVG was 15 minutes (range, 8-27 minutes). The median estimated blood loss was 1800 mL (range, 800-2100 mL). Intraoperative cell salvage was used in all cases. No intraoperative or postoperative complications occurred. No patient required blood transfusion. All patients tolerated a regular diet on postoperative day 2 and were discharged on postoperative day 4. Patients returned to work and full physical activity within 6 weeks (range, 2-6 weeks). At 6-month follow-up, computed tomography angiography demonstrated 100% patency of iliac artery grafts as well as of the GHVGs. ConclusionsTotal robotic laparoscopic CIA aneurysm repair is feasible in both unilateral and bilateral cases in carefully selected patients. The GHVG can be successfully deployed using robotic technique for IIA preservation during total robotic CIA aneurysm repair.
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