Prognostic benefits of early vascular surgical intervention in patients with major peripheral vascular complications following transcatheter aortic valve implantation.

OBJECTIVES: This study aimed to analyze the incidence, surgical management of major vascular complications, and outcomes in patients undergoing transfemoral (TF) transcatheter aortic valve replacement (TAVR) at our center after strict selection of the access route, carefully considering all known major predictors. METHODS: Data of 494 consecutive patients with pre-interventional multi-slice computed tomography (CT) of the aorta who had undergone TF TAVR from 2009 to 2019 were analyzed. RESULTS: In total, 23/494 (4.7%) patients had major vascular and access-related complications of peripheral vessels and/or infrarenal aorta. These included hematomas that met the Valve Academic Research Consortium 3-criteria of major vascular complications (7/494, 1.4%), arterial dissections (3/494, 0.6%), pseudoaneurysm (6/494, 1.2%), thrombus of the external iliac artery leading to acute limb ischemia (1/494, 0.2%), fistula (1/494, 0.2%), and perforation (5/494, 1.0%). In total, 17/23 (73.9%) major vascular complications required immediate endovascular and/or open surgery. In 16/17 (94%) cases, only 1 surgical procedure was performed. The long-term survival of patients with and without major vascular complications of the peripheral vessels was determined after 2 years. CONCLUSIONS: Early vascular surgery intervention reversed the mortality disadvantage in patients with major complications of the peripheral vessels after TAVR. This underscores the importance of immediate vascular surgery stand-by as an indispensable requirement.

Reversible biliary occlusion in a small animal model: first description of a new technique.

BACKGROUND: Experimental models with reversible biliary occlusion resulted in a high mortality of the animals, up to 20-60% according to the literature. Our aim was to assess a safe and valid technique for reversible biliary occlusion with a low mortality. METHODS: We randomized 30 rats into two groups: with bile duct occlusion (BDO, n=18) and with sham manipulation of the extrahepatic bile duct (control, n=12). We used a removable vascular clip for temporary occlusion of the extrahepatic bile duct. The clip was removed on postoperative day (POD) 2. On POD 2, 3, and 5, we measured the hepatocellular injury and metabolic function markers in serum. Activation of mononuclear cells (HIS36) and expression of regeneration markers [cytokeratin 19, hepatic growth factor (HGF)-α, and HGF-ß] were determined by immunohistochemistry. RESULTS: The survival rate was 96.67% (1/30); one animal died. The mortality in the BDO group was 6% (1/18) and that in the control group was 0% (0/12). BDO resulted in a sharp increase of hepatocellular injury and cholestatic parameters on POD 2 with a rapid decline till POD 3. Significantly strongest activation of Kupffer cells and expression of proliferation markers were found until POD 5 after BDO. CONCLUSION: The clip technique is a safe, cheap, and valid method for reversible biliary occlusion with an extremely low mortality.

Risk of gas embolism in hand-assisted versus total laparoscopic hepatic resection.

Laparoscopic hepatic resection represents an alternative to open surgery in patients with advanced underlying hepatic disease. Management of haemorrhage and the risk of gas embolism are the major problems in laparoscopic liver surgery. In this study, safety and efficacy of liver dissection using ultrasonic energy was investigated in hand-assisted versus total laparoscopic surgery. The study had a special emphasis on evaluating the risk of gas embolism during both procedures. Female pigs were divided into two groups for A) total laparoscopic (n=7), and B) hand-assisted laparoscopic (n=7) hepatic resection. For tissue dissection, an ultrasound aspirator (CUSA) was used in both groups. Laparoscopic procedure was performed under a CO2 pneumoperitoneum (intraperitoneal pressure: 12 mmHg). Before dissection, a Pringle manoeuver was carried out. The anaesthetized pigs were monitored haemodynamically by an arterial line and Swan-Ganz catheter. Transoesophageal echocardiography (TEE) was performed with special attention to the right atrium and ventricle. Gas emboli were graded according to size and correlated with haemodynamic and blood-gas data. In both groups, the ultrasound-aspirator enabled an effective tissue dissection. In total laparoscopic hepatic resection, TEE monitoring disclosed gas embolism in 5/7 (71%) animals. In 3/7 (42%) animals, gas embolism was accompanied by a sequence of cardiac arrhythmia. No direct correlation was noted between episodes of embolism and blood-gas variables. None of the pigs died after episodes of embolization. In hand-assisted liver resection, no air embolism was noted. The internal hand impressively facilitated organ exposure and provided an immediate and efficient haemorrhage control. The use of an ultrasound aspirator system enables an effective laparoscopic hepatic dissection. Total laparoscopic liver dissection is at increased risk for gas embolism, whereas hand-assisted laparoscopic procedure appears to reduce this risk. Due to tactile response and facilitated retraction of the liver parenchyma, the hand-assisted procedure shows impressive advantages in laparoscopic liver surgery.