Vascular Surgery - Science topic

Dear Hiroshi Mitsuoka ,

There should be also the option to share the pdf non public with the requesting person. I think that would be the best option when you are in doubt if you have the right to share the paper.

Best wishes Soenke

The attached file is only one slcie of the CT in an arterial phase. Also the window of contrast is not optimal. Normally in this patients bleeding comes directly from the fistula (esophagus wall).

Normally we perform aortic resection and iyenograft interposition, followed by an esophagus resection or endovac therapy, depending of the fistula size

In my humbled opinion deep hypothermic circulatory arrest (DHCA), total circulatory arrest (TCA), profound hypothermic circulatory arrest (PHCA), all are different names for the same procedure and techniques used for bloodless field in ( cardiac surgery) e.g great vessels, intracardiac and congenital and in other procedures and in sever trauma, some complicated cancer surgery and in resent research work, One of the anticipated medical uses of long circulatory arrest times, or so-called clinical suspended animation, is treatment of traumatic injury. In 1984 CPR pioneer Peter Safar and U.S. Army surgeon Ronald Bellamy proposed suspended animation by hypothermic circulatory arrest/ DHCA as a way of saving people who had exsanguinated from traumatic injuries to the trunk of the body. Exsanguination is blood loss severe enough to cause death. Until the 1980s, it had been thought impossible to resuscitate people whose heart stopped because of blood loss, resulting in these people being declared dead when cardiac resuscitation failed. Traditional treatments such as CPR and fluid replacement or blood transfusion are not effective when cardiac arrest has already occurred and bleeding remains uncontrolled. Safar and Bellamy proposed flushing cold solution through blood vessels of patients with deadly bleeding, and leaving them in a state of cold circulatory arrest with the heart stopped until the cause of bleeding could be surgically repaired to allow later resuscitation. In preclinical studies at the University of Pittsburgh during the 1990s, the process was called deep hypothermia for preservation and resuscitation, and then suspended animation for delayed resuscitation.

The process of cooling people with fatal bleeding for surgical repair and later resuscitation was finally called Emergency Preservation and Resuscitation for Cardiac Arrest from Trauma (EPR-CAT), or EPR.It is presently undergoing human clinical trials. In the trials, patients who experience clinical death for less than five minutes duration from blood loss are being cooled from normal body temperature of 37 °C to less than 10 °C by pumping a large quantity of ice-cold saline into the largest blood vessel of the body (aorta). By remaining in circulatory arrest at temperatures below 10 °C (50 °F), it is believed that surgeons have one to two hours to fix injuries before circulation must be restarted. Surgeons involved with this research have said that EPR changes the definition of death for victims of this type of trauma. So in short this is a technique evolved in early 1950s and the name is modified and changed finally associated with cerebral perfusion to reduce its complication and to gain extra timing without brain insult. as i mentioned above the different names e.g EPR-CAT is for the same technique of hypothermia using the same principles but different definition of the procedure.

based on a double-blind, multicenter, RCT comparing 1,000 mg tabs vs 500 mg tabs (same daily dose) in acute hemorrhoid, the authors concluded that "We have been demonstrated that the new single MPFF 1000 mg tablet has clinical acceptability and a good safety profile, comparable to that of MPFF 500 mg tablets. MPFF 1000 mg was as effective as MPFF 500 mg in reducing anal pain and bleeding. The new dose regimen should lead to better treatment adherence and consequently to better management of hemorrhoidal disease."

A loupe with at least 3 to 3.5x magnification should suffice.

Also check https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1959356/

I have made considerable studies on neonatal thrombocytopenia in Nigeria and will gladly join your team to investigate more on newborn platelets. My PhD thesis was on aetiology and pattern of neonatal thrombocytopenia at birth in Delta State, Nigeria. Other similar publications include

1. prevalence of thrombocytopenia at birth among apparently healthy newborns in Delta State, Nigeria

2. Alterations in platelet-to-Lymphocyte ratio and some white blood cell indices in neonatal thrombocytopenia

3. Submitted for publication: Some maternal and neonatal risk factors associated with early on-set neonatal thrombocytopenia in Delta State, Nigeria

4. Submitted for review: Variation in some haematological parameters in the newborn at different locations in Delta State, Nigeria

I have over 12 other publications in reputation journals.

My research experience with add value to your Lab

Dear Dumitri,

I have two RCTs from two friends and compatriots of mine (Pieter Klinkert and Fob van Det) whose publications I have uploaded and one excellent review for which I attached the link.

Vascular surgeons that prefer prothetic grafts over autologous vein grafts in infrainguinal bypass surgery are, in my opinion, lazy and ignorant of overwhelming evidence condemning that practice and should be sued by their patients who run a real risk for losing their leg(s)!

Amplatzer is an excellent option in case of rupture due to rapid solution, when possible,.

I believe that  speaking  about the best  endovascular technique in the treatment of visceral aneurysms(VA) the  answer is: It depends.

The pre operative planning in the cases of not ruptured VA and studing and choosing the best technique for each case individually!

You remove the media level together with the atherosclerotic plaque. After a good, clear, non-atheromatous thromboendarterectomy, the surface is devoid of plaques and quite clean. Also, during and after the procedure heparin is administered. 

I always close the arteriotomy with  a patch. If your hypothesis would be true, then everybody should also concern about thrombosis at the patch side.

Just perform an uneventful operation, leave a clean surface, close with a patch, give heparin after the procedure for 24-48 hours and continue with aspirin and clopidogrel, give statins; and don't worry about thrombus formation or re-stenosis.  

I favored to anastomose the aorto-femoral graft limb end-to-side to the common femoral artery with a tongue extending for about 1-2 cm in the profunda femoris artery, and the venous bypass (preferentially over non-autologous graft) end-to-side implanted in the graft limb. I used to implant a venous patch in the graft limb for anastomosis with the vein graft in case the vein graft appeared rather small (< 4 mm in diameter). In skinny patients and patients in whom skin healing might be jeopardized (for instance a redo) I would cover the graft and its anastomic area with a sartorial muscle flap over which the skin is closed with an continuous intracutaneous absorbable suture.

According to the Joint Commission, about 3 million PICC lines are placed annually in this country, 70% by nurses. The reference is in a paper available on my site: femoral cannulation...in the press in Wounds.

Perhaps This?

Indian Journal of Surgery

December 2015, Volume 77, Supplement 2, pp 248-252

Anatomical Study on the Variations in the Branching Pattern of Internal Iliac Artery

Or Perhaps this one

Anatomy Research International

Volume 2014 (2014), Article ID 597103, 6 pages

Variability in the Branching Pattern of the Internal Iliac Artery in Indian Population and Its Clinical Importance

If the bleeding is already controlled, and there is no availability for a surgeon with experience in HBP or cardiovascular surgery I think is better to reffer. 

On the other hand I think that you should prevent this. If the anatomy is not clear you should convert to laparotomy. In this scenario, if the hepatoduodenal ligament is severly  inflamed, especially in a chronic fashion, I think is safer an incomplete cholecistectomy, abandoning the gallbladder infundibulum. 

If you have a portal vein injury, more frequent are right branch injuries. In this case the referral is better.

In case of complete transection early repair is necessary. I am very curios about other answers. 

I suggest angioplasty followed by drug coated balloon therapy.  I recently treated a young patient with a variant of pseudoxanthma elastica who developed sma stenosis and  mesenteric ischemia .  Plain balloon therapy lasted 6 months with recurrence.  I initially approached the patient as if it were fibromuscular dysplasia.  But the patient recurred and I did cutting balloon therapy followed by DCB.  She is now nearly 1 year out without recurrence.

I think that the risk is very small, and should not affect your decision to technically optimize your procedure.  However as I said in CLI pts with diffuse SFA disease and probably poor tibial runoff I would avoid implanting a covered stent.

 

Yes. It looks interesting and useful.

Conventional arterial stents are designed not to grow into the intimal, medial or the adventitial layers. The stent is designed to distribute a uniform radial force sufficient to hold it in place reliably. Restenosis is and undesirable consequence that presents as a growth around the stent. If you want a stent to 'migrate' through the artery wall then it must be designed for that purpose. The form factor and profile for each strut should be reconsidered. Other considerations would be the edge effect of outward radial forces and perhaps other means of constricting the artery to provide a reactive force. These can be mechanically or pharmaceuticaly induced.

you need to do MRA to be sure not AVM , and treatment early is better in her condition by local injection , if failed surgical option is the  2ed .

I must say here when I started this topic I was using a very low LEED because I did no intumescence at all. I had no problem or complication, but gradually I increased my LEED to 60-80 J/cm and the usage of intumescence.

Hi,

We have worked with microbiologists to develop a clear policy for peri-operative prophylaxis in our patients. We have also developed guidelines for how to treat intravascular prosthetic infections, but do not have any specific guidelines for prevention of infection in vascular surgery other than this.

Should it be any different from any other types of surgery? It seems subjectively that other specialties such as cardiothoracic surgery and orthopaedics are more stringent with laminar flow and masks etc. but I am not sure how much difference this actually makes. I think limiting people moving in and out of theatre would help but I have no evidence to back this up!

This may be of interest: http://www.ncbi.nlm.nih.gov/pubmed/23317717

Sural nerve transplant is a hit and miss. 

Obviously there is  a logical trend for quicker and last invasive techniques.To say that there is no room for stripping at now would also be nonsense as there are still wide and numerous insufficient superficial veins even more problematic if there are large perforators that needs surgery.

I grasp the opportunity of this discussion to remind that venous insufficiency is part of a larger problem which is " the venous illness" and as such there is no one definitive technique or status: to day sclerotherapy, maybee to morrow endovenous ttmnt or even surgery and back to sclerotherapy.

Our patients have there own lives !! they are pregnant,working,taking care of their families and home,standing and not for granting resting and even less using compression therapy/prevention. So ... no way that any procedure could be considered as definitive and comprehensive ( except for a rather low percentage of patients ).

This is kind of a life long follow up that is written in the time for the patient ,its family and... the venous specialist be it a surgeon or a medical phlebologist.

Cardiac Sugeons worked with vein-to-coronary artery-anastomosis by magnet:

Arch Mal Coeur Vaiss. 2005 Apr;98(4):294-9.

[Preliminary clinical experience with the Ventrica automatic distal anastomosis system in coronary surgery].

[Article in French]

Klima U1, Farhat F, Beilner J, Maringka M, Bagaev E, Kirschner S, Haverich A.

Hi

if I well understand the restenosis was in the overlaping zone where there are two different materials in contact and a different radial force. It's very likely that these two factors have favored the neointimal iperplasia.

Yes. Seen a few patients. Usually need a combined surgical and adjuvant radiotherapy approach of treatment. 

You can connect you arterial pressure line on a small subcutaneous needle and after calibration you stuck the need in the venous graft (some surgeon use this needle for de-airing of venous bypass grafts) and you will get you pressure line on the scope. However it is probably not an option for arterial grafts.

Purpura fulminans (also known as "Purpura gangrenosa is an acute, often fatal, thrombotic disorder which manifests as blood spots, bruising and discolouration of the skin resulting from coagulation in small blood vessels within the skin and rapidly leads to skin necrosis and disseminated intravascular coagulation. Purpura fulminans lesions, once established, often progress within 24 to 48 hours to full-thickness skin necrosis or soft-tissue necrosis. Once purpura fulminans lesions progress to full-thickness skin necrosis, healing takes between 4-8 weeks and leaves large scars. Without treatment, necrotic soft tissue may become gangrenous, leading to loss of limbs.

The cardinal features of purpura investigations are the same as those of disseminated intravascular coagulation: prolonged plasma clotting times, thrombocytopenia, reduced plasma fibrinogen concentration, increased plasma fibrin-degradation products and occasionally microangiopathic haemolysis.

I think the first option is aggressive anticoagulation if patient is asymptomatic with close monitoring with TEE. I' ve seen 2 patient treated in this way with good result. TEVAR shows a theoretical embolic potential larger than a conservative approach. Open surgery is only for peculiar cases of associated lesion. Of course we ' ve to consider a second stage of treatment if the thrombus is due to an atherosclerotic burden of the aorta rather then to a coagulation disorder.

Hello. You should check this article.: Sfyroeras GS, Dalainas I, Giannakopoulos TG, Antonopoulos K, Kakisis JD, Liapis CD. Flow-diverting stents for the treatment of arterial aneurysms. J Vasc Surg. 2012 Sep;56(3):839–46.

Best to contact the company making the filters and ask for outdated stock

Does the patient exhibit any other signs of infection? Also is there either an elevated white count, or CRP level?

Differentiating between an inflammatory reaction to the PTFE graft versus infection can be tricky. If all you have is erythema in the absence of any systemic markers then I suggest you give a week of antibiotics and continue to observe the situation.

Dear All,

I  agree with Mr. Alexander , Muradi and Tarhan, but at this moment i do  prefer endovascular coil embolization or covered stent instead of multilayer to treat renal artery aneurism. Some reports are ambiguous about multilayer results.

I would like to ask Ms. A. Lombardi to send her suggestion of paper ?

Giuliànotti PC et al.

J Vasc Surg. 2010 Apr;51(4):842-9.

My email address : vascular@pauloocke.com.br

Endovascular Popliteal Aneurysms repair with covered stents is increasingly used. It is, however, unclear when an endovascular approach is preferred to traditional open repair with great saphenous vein bypass .

The Covered Versus Balloon Expandable Stent Trial (COBEST), a prospective, multicenter, randomized controlled trial, was performed involving 168 iliac arteries in 125 patients with severe aortoiliac occlusive disease who were randomly assigned to receive a covered balloon-expandable stent or bare-metal stent.

COBEST demonstrates covered and bare-metal stents produce similar and acceptable results for TASC B lesions. However, covered stents perform better for TASC C and D lesions than bare stents in longer-term patency and clinical outcome.

References

1BP Mwipatayi, S Thomas, J Wong, SE Temple, et al.: A comparison of covered vs bare expandable stents for the treatment of aortoiliac occlusive disease. J Vasc Surg. 54 (6):1561-1570 2011 21906903

I agree that endovascular procedure must be a recommendation but only after remission of inflamatory phase of disease .

I believe that ECST2 have conditions to answer this question!

Dear Peter Fellmer and Fellows ,

Do you have experience with Heparin Bonded Viabahn Stent-Grafts in lower extremity?If the answer is yes, which are your technical considerations to improve results?

I Agree but The UK Small aneurism Trial(Lancet 1998) showed that early elective surgery did not offer any all-cause survival advantage over regular ultrasound surveillance. The ADAM TRIAL (N Eng J Med 2002) published similar findings. The Eurostar(JVS 2004) registry indicate that even with the single outcome of freedom from aneurysm-related death following EVAR deployment,the rate of AAAs measuring between 4,0 and 5,4 cm is 3% within 5 years. Clearly ,there is very weak evidence to justify either open surgery or endovascular intervention in patients with aneurysms measuring less than 5,0 cm.

Thus CEUS may be a breakthrough in fact, some authors have considered the endotension an undetected endoleak. So as Prof.Maria said "it`s minimally invasive , more accurate than conventional ultrasonography in the EVAR follow-up . It is imaging "in real-time"."

Vikas Goyal said some of the reasons Why to prefer open access.

Dear Dr Fink,

we have quite a lot of experience in using omniflow as a regular graft in cases of prior graft infection. In this circumstances we did not see any aueurysmatic degegenartion, except one case with an anastomotic problem maybe due to not relay stich the mesh but anly the collagen. From my point of view it is very important to keep the mesh intact.Maybe when omniflow is used as an av access you destroy the mesh. Anyway we use in in a few replacement scenarios in case of infection as av access and had no problem. follow up might be 2 or 3 years.

Yours

P.Fellmer

Dear Gopi,we are using flow cytometry only in humans.With cytometry we use also /for viability/trypane blue staining.Viability is 75 to 95 per cent (after 16 h)and our procedure is successful,for.ex.see: Therapeutic angiogenesis for the salvage od ischemic limb,CLAHT,September 1-3,2011,Montevideo,Uruguay

What is the stability and viability of 133+/34- cells? Is it

possible to analyze (with relevant results) even the next day after bone

marrow collection?

The relationship between a continuous Parametric (Interval or ratio scaled) variable as independent variable and a dichotomous dependent variable can be evaluated using Logistic regression (Logit Regression). You could also, evaluate the relationship between dichotomous and interval/ratio as multiple independent variables and dichotomous dependent variable using Logistics Regression

Alejandro Latorre • last week in Bucaramanga, Colombia, in the 6 Colombian Phebology Simposium. The expertes in the treatment of varicose viens in conferences, videos, expert metting, about the question, experts defined according to their experience the following therapeutic alternatives

Options

1.- Surgery, Alejandro Latorre, Colombia

2.- EVLA +phlebectomy, Dra Marianne de Maessener, Belgica

3.- FOAM, dr P. Coleredge Smith, England

4.- Crossectomy + distal FOAM, Valete Guerrero, Mexico

5.- Phlebectomy only, without saphenous and saphenous femoral union, dr. Paul Pittaluga and Sylvain Chastenet , France

6.- Scleroterapy (Foam only tributaries without saphenous and saphenous femoral union) Dr. Angelo Scuderi, Brasil

finding: all alternatives are in place, with medium-term recurrences very similar, where above all the experience of the surgeon prevails

Thanks for your concepts

Surgery usually not indicated, I agree with Tristan. I suggest extensive evaluation of the patient and judicious follow-up. Atresia of the inferior vena cava may be associated with cardiac and visceral abnormalities, such as destrocardia, pulmonary stenosis, atrial defects, polisplenia, asplenia or situs inversus and complicated by deep vein thrombosis. DVT are usually bilateral and extensive, involving both iliac veins and an enlarged shadow of the azygos vein may appear on chest X-rays.