Gastroduodenal artery disconnection during liver transplantation decreases non-anastomotic stricture incidence

BackgroundThe hepatic artery is the only blood source nourishing the biliary duct and associated with biliary complication after liver transplantation (LT). Gastroduodenal artery (GDA) disconnection increased proper hepatic artery flow. Whether this procedure attenuates biliary non-anastomotic stricture (NAS) is not clear.MethodsA total of 241 patients with LT were retrospectively analyzed. The patients were divided into the GDA disconnection (GDA-) and GDA preservation (GDA+) groups. Propensity score matching (PSM) was administrated to reduce bias. Logistic regression was conducted to analyze risk factors for biliary NAS before and after PSM. Postoperative complications were compared. Kaplan-Meier survival analysis and log-rank tests were performed to compare overall survival.ResultsIn all, 99 patients (41.1%) underwent GDA disconnection, and 49 (20.3%) developed NAS. Multivariate logistic regression revealed that GDA preservation (OR = 2.24, 95% CI: 1.11-4.53; P = 0.025) and model for end-stage liver disease (MELD) score > 15 (OR = 2.14, 95% CI: 1.12-4.11; P = 0.022) were risk factors for biliary NAS. PSM provided 66 pairs using 1:2 matching method, including 66 GDA disconnection and 99 GDA preservation patients. Multivariate logistic regression after PSM also showed that GDA preservation (OR = 3.15, 95% CI: 1.26-7.89; P = 0.014) and MELD score > 15 (OR = 2.41, 95% CI: 1.08-5.36; P = 0.031) were risk factors for NAS. When comparing complications between the two groups, GDA preservation was associated with a higher incidence of biliary NAS before and after PSM (P = 0.031 and 0.017, respectively). In contrast, other complications including early allograft dysfunction (P = 0.620), small-for-size graft syndrome (P = 0.441), abdominal hemorrhage (P = 1.000), major complications (Clavien-Dindo grade ≥ 3, P = 0.318), and overall survival (P = 0.088) were not significantly different between the two groups.ConclusionsGDA disconnection during LT ameliorates biliary NAS incidence and may be recommended for application in clinical practice.     

Gastroduodenal artery: single key for many locks

Gastroduodenal artery (GDA) commonly arises from common hepatic artery, a branch of celiac axis. It holds a unique anatomical position that connects the foregut and midgut due to its intimate communications with foregut and midgut arterial supply. Its numerous anatomical variations have a significant impact on planning and performance of hepatopancreaticobiliary (HPB) surgery. Its close relation to the first part of duodenum, common bile duct and head of pancreas makes it susceptible for inadvertent bleeding during or after surgery, or due to various HPB pathologies. Also, a large number of vascular interventions rely on GDA and its branches. Careful preoperative planning is the key and a detailed knowledge and awareness of its variant anatomy is of paramount importance, be it liver resections, liver transplant, biliary and pancreatic resections and pancreatic transplant or transarterial procedures involving these arteries. GDA can also be a cause of gastrointestinal hemorrhage due to true or pseudoaneurysms and anatomy has significant implications on its management. The article provides a succinct review on relevance of GDA anatomy and variations and highlights that preoperative planning and intraoperative awareness of variations is the key to performance of safe HPB surgery and interventions.     

Spontaneous oscillation of the systemic arterial pressure during cardiopulmonary bypass in man. The effects of some drugs used during the operation

Summary Despite the fact that the blood flow maintained during cardiopulmonary bypass is rather steady in the extracorporeal pump output, the arterial pressure under high-dose fentanly anaesthesia quite often shows sinusoidal oscillations. In the present study the duration of an oscillatory cycle was on average 17.6±3.6 s, its amplitude 7.3±1.6 mm Hg and mean systemic arterial pressure 75±12 mm Hg. The oscillation is affected by the drugs used under bypass conditions. In our series of clinical observations the blood pressure oscillation disappeared under the influence of chlorpromazine, phentolamine, droperidol, and enflurane, and it disappeared or at least was distinctly attenuated under fentanyl, thiopental, diazepam, sodium nitroprusside, nitroglycerine, acebutolol, and potassium chloride. Pancuronium, atropine and furosemide appeared to be practically incffective. In spite of the fact that the drugs used affected several sites of the sympathetic efferent chain, the disappearance and attenuation of the oscillation were associated with a simultaneous decrease of blood pressure. Hence, it is suggested that the occurrence of the oscillations requires some level of peripheral vascular tone.     

Paediatric coronary artery bypass grafting for coronary hypoperfusion late after arterial switch operation

A case of left main coronary artery stenosis is presented in a boy late after an arterial switch operation, with significant ischaemia during exercise with good collateralisation through the right coronary artery. The problem was successfully managed with minimally invasive off-pump coronary artery bypass through median re-sternotomy.     

Validation of brachial artery pressure reconstruction from finger arterial pressure

OBJECTIVE: Measurement of finger artery pressure with Finapres offers noninvasive continuous blood pressure, which, however, differs from brachial artery pressure. Generalized waveform filtering and level correction may convert the finger artery pressure waveform to a brachial waveform. An upper-arm cuff return-to-flow measurement may be used to calibrate the blood pressure on an individual basis. We tested these corrective methods as implemented in the Finometer device. METHODS: Intrabrachial artery pressure (BAP) and finger artery pressures were recorded simultaneously in 37 cardiac patients, aged 41-83 years, who underwent a cardiac catheterization procedure. Finger artery pressures were compared after waveform filtering and level correction and after an additional return-to-flow calibration. Measurements were performed in supine and sitting positions. Accuracy and precision were considered clinically acceptable if the mean and standard deviation of the return-to-flow intrabrachial artery pressure (reBAP)-BAP differences were smaller than 5 +/- 8 mmHg (Association for the Advancement of Medical Instrumentation requirements). RESULTS: Finger artery systolic, diastolic and mean pressures for the group differed from that of intrabrachial artery pressure by -10 +/- 13, -12 +/- 8 and -16 +/- 8 mmHg, respectively. After waveform filtering and level correction the filtered level corrected arterial pressure differed by -1 +/- 11, -0 +/- 7 and -2 +/- 7 mmHg. After individual calibration, reBAP differed by 3 +/- 8, 4 +/- 6 and 3 +/- 5 mmHg. Comparable results were found in the sitting position but only when the supine return-to-flow calibration was used. CONCLUSION: Reconstruction of intrabrachial artery pressure from finger artery pressure with waveform filtering and level correction reduces the pressure differences substantially, with diastolic and mean within Association for the Advancement of Medical Instrumentation requirements. After one supine return-to-flow calibration, all pressure differences meet the requirements. Return-to-flow calibration should not be repeated in sitting position.     

Pulmonary artery interventions after the arterial switch operation: Unique and significant risks

Background: In the modern era, results of the arterial switch operation (ASO) for transposition of the great arteries are excellent. However, because of the LeCompte maneuver, there may be a propensity for development of pulmonary artery stenosis. We encountered atypical complications of pulmonary artery stenting in patients after the ASO, including aorto‐pulmonary fistula and coronary compression.
Methods: We performed a 10‐year retrospective review of catheterizations per‐ formed in patients after ASO in our institution with a focus on adverse events.
Results: Diagnostic and interventional catheterizations were performed in 47 pa‐ tients. In 29 patients, 37 interventional procedures performed, which included pul‐ monary artery angioplasty and/or stenting. In this group, there were five major adverse events (14%), including three aorto‐pulmonary fistulae and one coronary artery compression among patients having stent implantation or stent redilation. In addition, there were 6/37 (16%) intended stent procedures, which were aborted be‐ cause there appeared to be high‐risk of significant adverse events.
Conclusions: This review suggests that percutaneous intervention on pulmonary ar‐ tery stenosis after ASO has high‐risk and should be undertaken advisedly. Prior thor‐ ough evaluation of coronary arteries is mandatory as coronary reimplantation sites may be adjacent to sites of pulmonary artery stenosis. Furthermore, if pulmonary artery stent implantation or stent redilation is contemplated, the risk of stent fracture and possible AP fistula should be recognized. Primary use of reinforced covered stents should be considered.     

Growth of stenotic lesions after balloon angioplasty for pulmonary artery stenosis after arterial switch operation

Little is known about the growth potential of pulmonary stenotic lesions after balloon angioplasty (BA) in patients after the arterial switch operation. The aim of this study was to evaluate the growth potential of pulmonary stenotic lesions after BA and assess the midterm results of BA for pulmonary artery stenosis after the arterial switch operation. Thirty-seven patients who had undergone 52 procedures had repeat catheterization at a median of 43 years (range 1.2 to 9.3 ys) after BA. To adjust growth-related changes in the size of the pulmonary artery, the stenotic diameter was expressed as a percentage of normal (%N). An immediate increase of 63 +/- 45% in the stenotic diameter and a reduction of 51 +/- 33% in the pressure gradient occurred across the stenotic lesions after BA. The right ventricular-aortic systolic pressure ratio decreased from 0.67 +/- 0.24 to 0.51 +/- 0.12 after BA (p <0.0001). Compared with immediate data after BA, there was no significant change in the growth-adjusted diameter of the stenotic lesions (68 +/- 26 %N after BA vs 65 +/- 25 %N at follow-up, p = 0.08), and the pressure gradient (16 +/- 13 mm Hg after BA vs 20 +/- 21 mm Hg at follow-up, p = 0.10). The ventricular-aortic systolic pressure ratio also did not change (0.51 +/- 0.12 after BA vs 0.50 +/- 0.21 at follow-up, p = 0.57). Restenosis occurred in 3 of 26 vessels (12%) after successful BA in which the diameter increased >50% after BA. Our data suggest that pulmonary stenotic lesions after BA develop with age in growing children after the arterial switch operation, and the efficacy of the BA may be long lasting.     

Palmaz-Schatz stent for hepatic artery stenosis during hepatic arterial infusion chemotherapy.

Hepatic arterial infusion chemotherapy using an implantable port system was performed on a 40 year-old man with advanced hepatocellular carcinoma. When the in-dwelling catheter was inserted into the common hepatic artery (CHA), intimal dissection occurred as a result of the catheterization causing severe stenosis. On day 55 after intimal dissection, an in-dwelling Palmaz-Schatz stent was inserted after percutaneous transluminal angioplasty (PTA). CHA blood flow was shown to have improved on Digital subtraction angiography (DSA) and Doppler ultrasound after the in-dwelling Palmaz-Schatz stent. Thus a partial response was shown. The DSA from the implantable port system showed adequate patency 6 months after. This is the first report describing the usefulness of a Palmaz-Schatz stent for the severe stenosis of the CHA caused by the technique of catheterization.     

Nine-year patency of a vascular prosthesis used for portal vein reconstruction during pancreatoduodenectomy

We report a patient in whom a polytetrafluoroethylene (PTFE) graft used for reconstruction of the portal vein was confirmed to be patent 9 years after pancreatoduodenectomy (which was performed when he was aged 51 years). The patient had advanced cancer of the head of the pancreas. Pancreatoduodenectomy was performed, and 6 cm of the portal vein was resected. The portal vein was reconstructed with a PTFE graft (internal diameter 9 mm; length about 6 cm). The graft was demonstrated to be patent on angiography 3 years after the operation. A computed tomographic (CT) scan performed 9 years after the operation showed that the portal graft was still patent. About 2 years after the operation, the patient had been able to resume physical labor, similar to the work he performed before the operation.     

Transposition of great arteries and single coronary artery: a new surgical technique for the arterial switch operation

A single coronary artery can complicate the surgical technique of arterial switch operations, impairing early and late outcomes. We propose a new surgical approach, successfully applied in a 2.1 kg neonate, aimed at reducing the risk of early and late compression and/or distortion of the newly constructed coronary artery system.     

Stent supported angioplasty for coronary arterial stenosis following the arterial switch operation.

We present a case of a patient who underwent stent-supported angioplasty for left main bifurcation disease following the arterial switch operation. Prior to this procedure, the patient underwent surgical repair of the left coronary ostium and subsequently coronary artery bypass surgery with an arterial graft to the left anterior descending artery. We could not find a similar report in the literature.     

Carotid artery reconstruction for Takayasu's arteritis the necessity of all-autogenous-vein graft policy and development of a new operation.

BACKGROUND: We have adopted an all-autogenous-vein-graft policy in carotid reconstruction for Takayasu arteritis, namely an ascendo-right carotid and right subclavian (axillary) arteries bypass using a pantaloon vein graft for patients all of whose arch branches are occluded, and an extra-anatomical bypass from the right subclavian artery for patients whose brachiocephalic artery is the only arch branch that remains patent. This report is to elaborate on these operations and to assess the long-term outcome. METHODS: Six patients were operated on according to this policy; (5 women, 1 man, age range: 14 to 59 years (mean: 30). The indications for surgery were severe cerebral ischaemia that significantly interfered with their daily lives. The pantaloon vein graft bypass was performed in four patients, and an extra-anatomical bypass in two. The specific management protocol to prevent the "postbypass hyperperfusion syndrome" and cerebral oedema included a shunt procedure to the internal carotid artery using one limb of the pantaloon vein graft, induced hypotension just before the completion of the carotid reconstruction and the administration of a glycerine-fructose solution. RESULTS: Cerebral ischaemic symptoms disappeared in all patients. All but one, who died of a ruptured thoraco-abdominal aneurysm on the 35th postoperative month, are living a normal life with a patent graft. No suture line complications have as yet been encountered (follow-up: 10 to 205 months, mean: 126 months). CONCLUSIONS: Carotid vein bypass for Takayasu arteritis, particularly, the pantaloon vein graft bypass is recommended for those of whom all aortic arch branches are occluded, resulting in severe brain ischaemia. Perioperative blood pressure control is important for prevention of the hyperperfusion syndrome.     

Gastroduodenal mucosal injury during hepatic arterial infusion of chemotherapeutic agents. Lack of cytoprotection by prostaglandin E1 analogue

Eighteen colorectal cancer patients with liver metastases receiving hepatic arterial infusion of chemotherapeutic agents (mitomycin-C + 5-FUDR) were randomized to receive misoprostol (a prostaglandin E1 analogue) or placebo as a mode of cytoprotection against inadvertent gastroduodenal mucosal injury. Four of 10 patients on misoprostol and 3 of 8 patients on placebo developed gastroduodenal mucosal injury (p greater than 0.1), which was confirmed by endoscopy. Significant tumor responses to chemotherapy were equally distributed between the two groups. Although our sample size was small and type II error (false-negative trial) cannot be excluded, these data strongly suggest that prophylaxis with misoprostol does not prevent the acute gastroduodenal mucosal injury associated with hepatic arterial infusion of chemotherapeutic agents.     

Management of anomalous circumflex coronary artery from the neo‐pulmonary artery in an adolescent following neonatal arterial switch operation

A 15‐year‐old male with transposition of the great arteries presented with exertional chest pain. He was found to have a circumflex coronary artery from the neo‐pulmonary artery that had not been transferred during his arterial switch operation. The circumflex coronary artery, fed through collaterals from a re‐implanted single coronary artery, resulted in coronary steal. This report describes a management pathway to treat this rare anomaly. © 2014 Wiley Periodicals, Inc.     

Outcomes after arterial switch operation for simple transposition

Without intervention, babies born with transposed great arteries (TGA) are doomed to a rapid death. Jatene and coworkers deserve the credit for performing the first successful arterial switch operation (ASO) in a patient with TGA and ventricular septal defect (VSD) in 1975. Since then ASO has become the procedure of choice in most medical centers. This review article summarizes the historical aspects of arterial switch operation and assesses this procedure's outcomes.