Liver graft vascular variant with 3 extra-hepatic arteries

ABSTRACT:Vascular anatomy of the liver is varied,and the "standard"anatomy is seen in 55%-80%of cases.It is very important that extrahepatic arteries are identified precisely at the time of graft procurement to avoid injuries that might compromise the liver function.In the present case the liver donor had the vascular anatomy of Michels typeⅦ,e.g.a hepatic artery originating from the celiac trunk and going to the left lobe,an accessory left hepatic artery coming from the left gastric artery,and a replaced right hepatic artery coming from the superior mesenteric artery.This pattern of vascular supply is uncommon,representing less than 5%of cases.The replaced hepatic artery was reconstructed in the back-table with polypropylene suture 7.0 by connecting it to the stump of the splenic artery,and the celiac trunk of the graft was anastomosed to the recipient common hepatic artery.     

Percutaneous cervical carotid artery access with stenting of the left internal carotid artery in an elderly patient

To describe the successful endovascular treatment in a nonagenarian with symptomatic internal carotid artery stenosis using direct carotid artery access. An independent 98 year-old man was admitted to our hospital for symptoms of progressive weakness with disorientation and dysphasia. Carotid Duplex ultrasonography was performed which revealed a totally occluded right internal carotid artery and high grade stenosis of the left internal carotid artery by velocities of 608/240 cm/sec. The patient refused surgical endarterectomy and thus he was referred for carotid artery stenting. Using the femoral artery approach and multiple catheter techniques, access to the common carotid artery could not be accomplished safely. The procedure was aborted and he was therefore brought back to the catheterization laboratory the following day for direct carotid access. Carotid artery stenting was accomplished by using of a 6F sheath percutaneously in the left common carotid, cerebral protection device (CPD) and a Nitinol stent. The patient was discharged the following day without complications. At 14 months follow-up the patient is functional and independent without recurrence of symptoms. Carotid artery stenting via direct access can be accomplished in patients when the femoral artery approach is anatomically prohibitive. In this case of advanced age and the patient’s refusal for surgery, direct carotid access was his only option.     

Novel treatment of coronary artery fistulae concealing severe coronary artery lesion: using thrombus aspiration catheter as a delivery guide

In this case report, we present the occlusion of multiple coronary artery fistulaes originating from proximal left anterior descending （LAD） and fight sinus valsavla and empting to the pulmonary artery at the same place. We occluded LAD fistulae by using thrombus aspira- tion catheter as a delivery guide. To the best of our knowlege, this is the first case of occlusion of coronary fistulaes with the help of throm- bus aspiration catheter. Our experience may suggest that thrombus aspiration catheters can be used in treating coronary artery fistulaes with difficult anotomv.     

Recurrence of resistant hypertension after renal artery stent implantation： A case report

Takayasu＇s Arteritis is a chronic non-specific inflammatory vascular disease involving the aorta and its major branches. Takayasu＇s arteritis is one of important reason for renal artery stenosis（RAS） which may result in severe hypertension. Angioplasty, preferably with stenting, is recommended in RAS secondary to atherosclerosis. However, the safety and efficacy of stent implantation is still unclear in RAS caused by Takayasu＇s arteritis. In order to raise the awareness for the importance of Takayasu＇s arteritis in renal artery disease and further to discuss the endovascular revascularization strategies, we are going to present a case report regarding RAS resulted by Takayasu＇s arteritis and provide a timely summary and update on current understanding.     

The Changes of Coronary Artery Stenosis on FCG-A New Method of Diagnosing Ischemia Heart Disease

<正> Frequency domain correlative cardiogram （FCG） is a new developing technique in noninvasive measurement. It is not clear that FCG diagnoses cardiac ischemia. This study was made cn dogs with different degree of coronary artery stenosis, the relationship between the changes of cardiac ischemia and FCG is discussed in this paper.In open chest dogs, an external stenosis was produced by a micrometer constrictor cn the left circumflex coronary artery or the left anterior dis-cending coronary artery, which caused three different degrees of coronary artery stenosis: namely mild, moderate and severe stenosis. Coronary blood flow （CBF）, aortic pressure, left ventricular pressure, systolic time intervals, admittance plethysmography, two-dimensional echocardiography and FCG were synchronously recorded.The result showed that FCG did not change when CBF was slightly decreased; FCG had a significant change when CBF was decreased to 40% of resting value; there was a remarkable change in FCG when CBF was decreased to 80% of resting value. The amplitude of change in FCG was in concordance with that of decreased CBF. A positive correlation between the changes of FCG and CBF was found.So we think that FCG is a valuable diagnostic method for myocardial ischemia when CBF is obviously decreased. It can reflect the degree and extensiveness of myocardial ischemia.     

Predictors of atrial fibrillation after coronary artery bypass graft： a meta-analysis

Objectives Postoperative atrial fibrillation （AF） has been associated with less favorable outcomes in patients undergoing coronary artery bypass graft surgery （CABG） and may result in increased post-operative morbidity and mortality. A systematic review and meta-analysis of published studies was conducted to examine the risk factors of occurrence AF after CABG. Methods Using the Medline database, the Cochrane clinical trials database and online clinical trial databases, we reviewed all randomized controlled trials （RCTs） and observational studies examining the risk factors of occurrence of AF after CABG. We searched for literature published April 2009 or earlier. Results Our review identified 8 studies （observational studies）, involving 14548 patients, that examined the risk factors of occurrence of AF after CABG. Although studies provide conflicting results, the overall outcomes suggests that advanced age, previous hypertension, numbers of bridge vessels may increase the occurrence of AF after CABG, while no significant difference of diabetes, preoperative myocardial infarction, and preoperative medication of 13 -Blocker have been observed between the AF patients and no-AF patiens. Conclusions Patients with advanced age, previous hypertension and more numbers of bridge vessels had higher risk for the occurrence of AF after CABG, and perioperative medication and care must be intensified to decrease the postoperative occurrence ofAF（J Geriatr Cardio12009; 6：162-167）.     

Carotid artery angioplasty and stenting in elderly patients： the advantage of being an interventional cardiologist

Objective Carotid angioplasty and stenting （CAS） has been suggested to be the procedure of choice in patients with high risk cardiovascular profile. Unfortunately, such patients are often aged with several comorbidities, such as a high prevalence of coronary artery disease, peripheral artery disease and hostile anatomy that complicate the CAS performance. We sought to evaluate the results of CAS in elderly patients, outlining the encountered challenges and the eventual proposed global cardiovascular management. Methods We retrospectively searched the database for patients 〉 65-year-old who were referred to Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, over a 24-month period （December 2007-November 2009） for CAS. Coronary angiography and peripheral screening were performed in all patients. All eventual challenges and related solutions were analyzed. Results Totally, 160 patients were enrolled. Among which, 50 patients （31.2%, mean age 80 ~ 6.4 years） underwent CAS over a 24- month period： 24 patients （48%） had concurrent coronary artery disease （three-vessel in 7 patients, bivessel in 8 patients, single vessel in 5 patients and left main in 4 patients）; 13 patients （26%） and peripheral artery disease at the site of arterial access; 15 patients and type III aortic arch （30%）, 7 patients severe tortuosity of the common carotid artery （14%）, and 8 angulated takeoffof carotid or internal artery （16%）. Concurrent percutaneous coronary intervention was performed in 14 patients, including 3 patients with left main disease. Concurrent peripheral intervention was performed in 7 patients （ all with bilateral common or external critical disease） due to the impossibility to gain another access. Successful carotid cannulation was achieved in all patients with hostile neck. Two-wire technique has been used in 17 patients, three-wire technique in 9 patients, and four-wire technique in 4 patients. Conclusion Elderly patients submitted to CAS represent a complex and challenging subgroup in which often cardiac and peripheral technical expertise is required to gain success of the procedure： interventional cardiologists are probably the preferred performers in such complex patients （JGeriatr Cardio12010; 7：3-6）.     

Variations and reconstruction of the hepatic artery in liver transplantation

Any surgical refinement and innovation is certain to improve the long-term survival of recipients following liver transplantation. In the past de- cade, the shortage or donor organs has prompted us to use partial liver graft in split liver transplantation and living donor liver transplantation. As an anatomic problem in a successful transplantation, which actually is beyond the category of anatomy, the variations and reconstruction of hepatic vasculatures have drawn much attention of surgeons.     

Ministernotomy for minimally invasive coronary artery bypass grafting

Background Through a ministernotomy ＂J shaped approach, left internal mammary artery （LIMA） bypass grafting to the left anterior descending artery （LAD） can be performed safely off-pump. To achieve a complete revascularization, percutaneous coronary interventions （PCI） with drug eluting stent implantation to other coronary arteries was used. We reported outcomes of the treatment of multivessel coronary artery disease with minimally invasive coronary artery bypass （MICAB） and PCI. Methods Between January 2009 and Dec 2012, 14 patients （11 males, 3 females, mean age was 64.8 _ 10.1 years. Two-vessel disease account for 35.7% （5/14） of these patients, three-vessel disease 64.2% （9/14） （Table 1）. All patients underwent a minimally invasive coronary artery bypass grafting via mini-sternotomy ＂J＂ shaped approach. Seven patients were followed by PCI, 7 for obtuse marginal circumflex, 5 for right coronary artery （RCA）. Angiographic assessment of graft patency was performed in all patients during the PCI procedure. The clinical follow-up period lasts from 11-24 months. Results The in-hospital mortality was 0%. There was neither conversion to a full median sternotomy nor intraoperative complications. Ventilation time was 6.6 ＋_ 4.1 h. Blood loss ranged 341 ＋_ 78.8 mL. ICU stay ranged 22.3 _ 12.8 h. Hospital postoperative stay lasted for 6.5 ＋ 1.6 days. Prior to PCI patients showed 100% patent left internal mammary artery. One patient had mediastinitis （Tables 2-3）. Rate of freedom from cardiac reintervention during the follow-up period was 92.8% （13/14）. Conclusions The inferior J-shaped sternotomy is simple, reproducible, and the safest technique for performing minimally invasive coronary bypass surgery. MICAB ＋ PCI is also safe, feasible and efficacious.     

Surgical anatomy of the innervation of pylorus in human and Suncus murinus, in relation to surgical technique for pylorus-preserving pancreaticoduodenectomy

AIM: To clarify the innervation of the antro-pyloric region in humans from a clinico-anatomical perspective. METHODS: The stomach, duodenum and surrounding structures were dissected in 10 cadavers, and immersed in a 10mg/L solution of alizarin red S in ethanol to stain the peripheral nerves. The distribution details were studied to confirm innervations in the above areas using a binocular microscope. Similarly, innervations in 10 Suncus murinus were examined using the method of whole-mount immunohistochemistry. RESULTS: The innervation of the pyloric region in humans involved three routes: One arose from the anterior hepatic plexus via the route of the suprapyloric/ supraduodenal branch of the right gastric artery; the second arose from the anterior and posterior gastric divisions, and the third originated from the posterior-lower region of the pyloric region, which passed via the infrapyloric artery or retroduodenal branches and was related to the gastroduodenal artery and right gastroepiploic artery. For Suncus murinus, results similar to those in humans were observed. CONCLUSION: There are three routes of innervation of the pyloric region in humans, wherein the route of the right gastric artery is most important for preserving pyloric region innervation. Function will be preserved by more than 80% by preserving the artery in pylorus-preserving pancreaticoduodenectomy (PPPD). However, the route of the infrapyloric artery should not be disregarded. This route is related to several arteries (the right gastroepiploic and gastroduodenal arteries), and the preserving of these arteries is advantageous for preserving pyloric innervation in PPPD. Concurrently, the nerves of Latarjet also play an important role in maintaining innervation of the antro-pyloric region in PPPD. This is why pyloric function is not damaged in some patients when the right gastric artery is dissected or damaged in PPPD.     

Long-term patency of saphenous vein and left internal mammary artery grafts after coronary artery bypass surgery: results from a Department of Veterans Affairs Cooperative Study

OBJECTIVES: This study defined long-term patency of saphenous vein grafts (SVG) and internal mammary artery (IMA) grafts. BACKGROUND: This VA Cooperative Studies Trial defined 10-year SVG patency in 1,074 patients and left IMA patency in 457 patients undergoing coronary artery bypass grafting (CABG). METHODS: Patients underwent cardiac catheterizations at 1 week and 1, 3, 6, and 10 years after CABG. RESULTS: Patency at 10 years was 61% for SVGs compared with 85% for IMA grafts (p < 0.001). If a SVG or IMA graft was patent at 1 week, that graft had a 68% and 88% chance, respectively, of being patent at 10 years. The SVG patency to the left anterior descending artery (LAD) (69%) was better (p < 0.001) than to the right coronary artery (56%), or circumflex (58%). Recipient vessel size was a significant predictor of graft patency, in vessels >2.0 mm in diameter SVG patency was 88% versus 55% in vessels 2.0 mm in diameter.     

Short- and medium-term study of arterial grafts and native coronary circulation after in situ implant of the internal mammary artery

The internal mammary artery (IMA) is being increasingly utilized as a conduit for myocardial revascularization, based on its higher long-term patency. The aim of this study is the serial assessment of the changes of native coronary vessels after IMA coronary anastomosis. Twenty-six consecutive patients (24 males and 2 females, mean age 56.4 years) received an IMA graft on the left anterior descending (LAD) artery. IMA coronary anastomosis was single in 11 patients and double (LAD and diagonal branch) in the remaining 15 cases. In 23 patients (88.5%) at least one associated saphenous vein graft was inserted. Post-operatively, no new Q waves or low-output syndromes were observed. Follow-up angiographic study, including selective opacification of the IMA graft, was carried out after 1 month and after 1 year. The cumulative patency rate of IMA grafts was 97.7% after 1 month. The LAD stenosis proximal to the IMA anastomosis progressed to total occlusion in 6 patients (28.5%), all of them with a preoperative stenosis ranging from 90 to 99%; its diameter remained unchanged in 6 patients (28.5%), while a reduction of the coronary narrowing greater than or equal to 20% was observed in 9 patients (43%). Preoperatively, the LAD stenosis of the latter groups ranged from 70 to 90%. Severity of residual stenosis and relative diameters of LAD artery and IMA graft influenced the competitive flow distribution through these vessels.(ABSTRACT TRUNCATED AT 250 WORDS)     

Delayed pleuropulmonary complications following coronary artery revascularization with the internal mammary artery

We have seen four cases of delayed postoperative pleuro-pulmonary complications associated with use of the internal mammary artery (IMA) conduit. In each case the left IMA was used as a bypass conduit to the left anterior descending (LAD) coronary artery. In two of the instances the complications were life-threatening to the patients. Each patient was left with symptomatic residual roentgenographic changes. The IMA is becoming the graft of choice for coronary artery revascularization. The potential for delayed pleuropulmonary complications associated with use of this graft is not well recognized.     

Coronary artery bypass grafting by utilizing the internal mammary artery graft in 100 Japanese patients

The internal mammary artery (IMA) grafting for myocardial revascularization was performed in 100 Japanese patients during a three-year period. There were 86 males and 14 females with the mean age of 58 +/- 9 (37 approximately 75 year-old). Unilateral IMA was used in 88 patients and bilateral IMA was used in 12 patients. Sequential IMA grafting was performed in 5 patients. The sites of IMA grafting were 91 left anterior descending arteries (LAD), 16 diagonal branches, 8 circumflex arteries and 2 right coronary arteries. Saphenous vein or gastroepiploic artery was concomitantly used to bypass the other coronary arteries in 90 patients. The number of distal anastomosis ranged from 1 to 6 and the mean was 2.8 per patient. Two patients died within 30 days and one patient died at 3 months after surgery. Perioperative myocardial infarction was noted in 3 patients. Symptomatic relief was obtained in 94 (97%) of 97 survivors. The patency of the IMA graft at mean 2.2 postoperative months was 97% (58/60) in LAD, 100% (14/14) in the diagonal branch, 100% (5/5) in the circumflex artery, 100% (1/1) in the right coronary artery, and 98% (78/80) in over-all grafted coronary arteries. Pre- and postoperative exercise thallium scintigraphy in 13 patients, who received the IMA graft to severely stenosed LAD, showed significant improvement of the washout ratio (from 33.1 +/- 16.9% to 47.4 +/- 14.8%) which was nearly equivalent to that of the saphenous vein graft to LAD (from 24.8 +/- 6.2% to 48.1 +/- 6.6%, n = 7).(ABSTRACT TRUNCATED AT 250 WORDS)     

Recruitable patency of the internal mammary artery graft.

A 46-year-old man underwent two coronary bypass operations and three percutaneous interventions over a period of 18 years. A non-functioning internal mammary artery (IMA) graft, was observed shortly after the second surgery. This graft was anastomosed to the left anterior descending (LAD) that had adequate flow from an older vein graft placed during the first surgery. Over the ensuing 8 years, the IMA graft regained patency after progressive occlusive disease in the competing vein graft.     

Noninvasive quantitative evaluation of the patency of internal mammary artery grafts to the left anterior descending coronary artery by transthoracic Doppler echocardiography

OBJECTIVES: Evaluation of left anterior descending coronary artery (LAD) flow by transthoracic Doppler echocardiography (TTDE) may allow assessment of anastomosis of the internal mammary artery (IMA) grafted to the LAD. This study tested the feasibility of TTDE to evaluate anastomotic stenosis of the IMA grafted to the LAD. METHODS: TTDE was performed in 66 patients (48 men and 18 women, mean age 67 +/- 10 years) with left or right IMA grafts to the LAD. The distal IMA flow at the anastomosis was visualized and the percentage stenosis was evaluated by the continuity equation using the anastomotic and pre-anastomotic flow velocity measured by TTDE as well as by angiography. If the anastomotic flow was not visualized by TTDE, the absence of augmented diastolic flow of the proximal IMA, by using the supraclavicular approach, with diastolic to systolic mean velocity ratio < 0.25 was considered as anastomotic occlusion. RESULTS: Anastomotic flow was visualized and the percentage stenosis was obtained by the continuity equation in 50 patients. In 4 of the remaining 16 patients, the proximal IMA flow by TTDE showed the occlusion pattern. In these 54 (82%) patients, the percentage stenosis by TTDE showed a significant correlation with that by angiography (r2 = 0.86, p < 0.0001). In all the remaining 12 patients with the patent proximal IMA pattern but without visualized anastomotic flow, the patency was confirmed by angiography. CONCLUSIONS: TTDE enables direct visualization and quantitative evaluation of the anastomotic patency in patients with IMA graft to the LAD.     

应用多普勒导丝技术研究内乳动脉与冠状动脉前降支血流动力学

目的 比较内乳动脉(IMA)与冠状动脉前降支(LAD)相关血流动力学参数。方法应用血管内多普勒导丝记录22例患者IMA和LAD的平均峰值流速(APV)、舒张收缩流速比(DSVR),造影测量血管直径(D),计算血流量(F)。结果IMA的APV和DSVR与LAD相比有明显差别[分别为(38±12)cm/s VS(23±7)cm/s,P<0.001;0.6±0.3VS 2.4±1.1,P<0.001)];IMA的D和F明显低于LAD[分别为(2.3±0.4)cm vs(3.2±1.1)cm,P<0.05;(90±12)ml/min vs(260±12)ml/min,P<0.001]。结论IMA收缩期供血为主,血流量小;而LAD舒张期供血为主,血流量大。     

Retrograde internal mammary to coronary artery anastomoses

In an effort to expand the utilization of the internal mammary artery (IMA) for revascularization of the distal coronary artery branches, distally pedicled retrograde internal mammary arteries (retro-IMA) were evaluated in 10 mongrel dogs with a mean weight of 38 +/- 13 kg. One IMA was transected at it's origin (retro-IMA) and compared to the contralateral IMA which was transected at the level of the 5th intercostal space. At a mean systemic pressure of 68 +/- 15 mmHg the mean pressure measured at the tip of the IMAs with antegrade flow was 63 +/- 14 mmHg in the retro-IMAs with retrograde flow (p less than 0.05; pressure ratio 0.8). With the same mean systemic pressure, mean antegrade free flow of the IMAs was assessed 97 +/- 43 ml/min versus 48 +/- 13 ml/min in the retro-IMAs with retrograde flow (p less than 0.005; flow ratio 0.5). Left retro-IMA to coronary artery anastomosis was performed in 6 animals to the distal left anterior descending (LAD) coronary artery and in 2 animals to the distal left obtuse marginal branch. Right retro-IMA to coronary artery anastomosis to the right posterior descending coronary artery was performed in 2 animals. The LAD coronary artery was ligated proximally to the retro-IMA to coronary artery anastomosis while the retro-IMA remained crossclamped. After documentation of significant ischemia (EKG, left atrial pressure), the crossclamp of the retro-IMA graft was removed. Subsequent normalisation of EKG and left atrial pressure occurred in all animals. We conclude that the canine retro-IMA delivers significant retrograde flow and discuss a possible use in humans.     

Left internal mammary artery grafting to left anterior descending coronary artery by minimally invasive direct coronary artery bypass approach

New surgical techniques for the treatment of the isolated lesion of the left anterior descending coronary artery (LAD) include off-pump surgery, minimal access to the heart, and endoscopic or computer enhanced coronary artery bypass surgery. The term minimally invasive direct coronary artery bypass surgery (MIDCAB) is related to a leftside minithoracotomy, the harvest of the left internal mammary artery (IMA) under direct vision, and an anastomosis performed between IMA and LAD under direct vision, using the technique of mechanical local immobilization by a special device. Alternative techniques include endoscopic harvesting of the IMA, or as a new and still experimental approach, the closed-chest total endoscopic coronary artery bypass grafting (TECAB) with the use of a high tech telemanipulator system. The currently reported results demonstrate the safety of MIDCAB surgery (30-day mortality < 0.5%, perioperative myocardial infarction < 2%, early patency rate between 95% and 98%). Mid-term results after 6 months have shown a patency rate between 94% and 97%, and more than 90% of the patients are without any angina symptoms. Due to this promising results MIDCAB is an alternative treatment for high-grade LAD lesions.     

Sequential internal mammary artery (IMA) grafts in coronary artery bypass surgery

Since 1972, double or triple left IMA bypasses have been made on 61 consecutive patients with a total of 123 distal anastomoses to the LAD or to the LD branches of the LAD. There were 54 additional vein grafts with 102 distal anastomoses. The number of single IMA grafts in the same period of time was 400. Hospital mortality was 2 patients (3.3%), with a late mortality of 7 patients (11.3%), 2 of them being heart-related, one of hypernephroma, one suicide, and of unknown cause in the remaining 3 patients. Five patients refused postoperative angiography. There were 50 patients with one or more postoperative angiograms available for the analysis after a mean follow-up time of 35.1 (0.5 to 128) months. The late patency of the left IMA anastomoses was 97% (98/101) and 82.4% (84/102) of the vein anastomoses. There were 2 anastomotic left IMA occlusions to the LD at 2 weeks and 10 months, respectively, and to LAD at 13 months. No left IMA graft had become completely occluded. According to the trend analysis, there was a 97.5% patency at 5 years, and 95.7% at 10 years with left IMA grafts compared to 78.4 and 67.9, respectively, with vein grafts. Ten left IMA grafts were dilated, 2 narrowed and 36 unchanged at the late angiography. Sequential left IMA graft, in appropriate cases seems to result in the most superior patency rate of all types of grafts.