Analysis of a Large 19-Year Database in Vascular Surgery in Southern Iran: Evaluation of Trends and Limitations.

BACKGROUND: Large databases with data elements of clinical interest are essential for carrying out high-quality observational studies. Such databases have become increasingly popular for clinical research in fields like vascular surgery. Our goal is to create a solid and reliable database of the patients who have been admitted and undergone different vascular surgery procedures over 19 years and to provide surgeons with the current trends and limitations in managing patients with vascular disease. METHODS: The database of patients operated in Namazi Hospital, the referral center for vascular surgery in Southern Iran, from 2001 to 2019, was retrieved and patients undergoing vascular procedures were parted. Demographic and perioperative data were evaluated and patients were categorized into subgroups based on the type and cause of operation. All data were analyzed with SPSS version 26.0 (IBM, NY, USA). RESULTS: During the period of our study, a total of 226,051 operations were performed at the Namazi Hospital. Among these operations, 6,386 (2.82%) vascular surgery-related operations were entered into our study. The average age of the patients in our study was 53.22 ± 18.92 years (range: 1 day old-97 years) and 4,061 (63.6%) were male. Furthermore, 147 (2.3%) were operated by multiple surgeons. Moreover, 798 (12.5%) of the patients were admitted postoperatively to the intensive care unit, while the rest (5,588; 87.5%) in the common surgery ward. The cause of operation in 609 (9.5%) of the cases was trauma. Based on wound categorization, 5,132 (80.4%) were type I (clean). The most frequent operation performed in our center was arterial reconstruction and limb revascularization (31.4%), followed by hemodialysis access (31.3%). The most frequent surgery in the age group of less than 18 years was fasciotomy, in the 19-40 years group was tumor (56.8%) and varicose veins (52.9%), and in the 41-60 years group was implantation of ventral venous port catheter (47%). Only carotid and thoracic outlet syndrome surgeries were significantly higher in females. The remaining operations were all significantly higher among male patients. Finally, carotid body tumor surgery was the most frequent operation requiring intensive care unit monitoring. CONCLUSIONS: We demonstrated, for the first time, an overview of vascular surgeries performed in a referral tertiary center in Southwest Iran. There is an increase in the number of surgical procedures in the field of vascular surgery, and large databases will be a valuable tool for addressing critical problems in this field and also the healthcare system.

Renal revascularization by a pedicled intestinal segment wrapping the kidney: a new method for kidney revascularization.

BACKGROUND: Renal artery stenosis is caused by a heterogeneous group of diseases, including atherosclerosis and fibromuscular dysplasia, which can be treated medically, via endovascular techniques, or by open revascularization; however, satisfactory and effective results are not always obtained. We aimed to assess the possibility of renal revascularization by a pedicled intestinal segment wrapping the kidney. METHODS: Five dogs were operated on at three steps. At the first step, laparotomy was performed, and the right kidney was released. Subsequently, an 8-10 cm segment of jejunum was separated longitudinally, and mucosectomy was done. This intestinal patch wrapped up the kidney. After eight weeks, the kidney and the intestinal patch were analyzed, and the renal artery was ligated. After four weeks, the kidney and the intestinal patch were sent for pathological evaluation. RESULTS: At the 12th week of evaluation, no evidence of abscess formation or collection was seen. All kidneys had a normal color, consistency, and size. All renal cells were alive, and neither atrophy nor necrosis was seen. Glomerulus and tubules were intact, and no inflammatory change was visible. Furthermore, thick wall vasculature was inspected in a fibromuscular tissue, rising from the intestinal flap toward the kidney. One of the dogs expired due to peritonitis and sepsis in the fifth week. CONCLUSION: In our study, indirect perfusion of the kidney by an intestinal patch was achieved successfully. This represents new hope in patients suffering from chronic renal failure who underwent former medical and surgical interventions with undesirable results.

Different cytokine patterns induced by Helicobacter pylori and Lactobacillus acidophilus extracts in PBMCs of patients with abdominal aortic aneurysm.

Abdominal aortic aneurysm (AAA) is a degenerative inflammatory disease with unknown etiology. AAA is characterized by abdominal aortic dilatation more than 3 cm and is often asymptomatic, but the rupture of aneurysm can lead to death. Age, smoking and male sex are major predisposing factors of AAA. This study compares the effect of Helicobacter (H.) pylori and Lactobacillus (L.) acidophilus on the cytokine profile of PBMCs of 5 men with abdominal aortic aneurysm (AAA) and 5 men with normal/insignificant angiography, CT-Scan and ultrasonography results in the single-culture and in the co-culture with HUVECs. IL-2, IL-4, IL-5, IL-6, IL-9, IL-10, IL-13, IL-17A, IL-17 F, IL-21, IL-22, IFN-γ and TNF-α were measured in culture supernatants using a commercial fluorescent-labeled-bead assay. In general, CagA+ H. pylori-extract induced higher production of IFN-γ, IL-13 and IL-21 by PBMCs. Treatment of patients' PBMCs with CagA+H. pylori-extract induced Th2 cytokines while treatment of controls' PBMCs with CagA+H. pylori-extract increased Th1 cytokines. In the co-culture, however, patients' PBMCs produced Th1 cytokines irrespective of extract treatment, while controls' PBMCs produced Th2 cytokines and decreased IL-10. CagA+ H. pylori- as well as L. acidophilus-extract induced higher levels of IL-9 by controls' PBMCs in co-culture with HUVECs than patients (P = 0.05 and P = 0.01). The cytokine pattern of PBMCs induced by CagA+ H. pylori- and L. acidophilus-extracts in the co-culture with HUVECs shows differences in AAA patients and in comparison to controls. Decreased secretion of IL-9, IL-21 and IL-22 by PBMCs of patients treated with CagA+ H. pylori extract in co-culture, as opposed to non-AAA controls may indicate the active role ECs play in AAA. Simultaneous production of IL-10 and Th1 cytokines in patients and pronounced Th2 cytokines in controls in response to both bacteria may point to the inherent differences between patients and controls, which need further investigation.

Inferior Vena Cava Repair Using Diaphragm in Animal Model.

BACKGROUND: Repair and reconstruction of the vena cava with an autologous vein requires multiple incisions. Prosthetic material is linked with an increased risk of infection and thrombosis. Therefore in this study, we created an animal model of vena cava repair using the diaphragm. The objective of this study is to assess the feasibility and outcomes of using diaphragm for the repair and replacement of the inferior vena cava (IVC) after resection of a part of the infrarenal IVC in an animal model, as it may be encountered in trauma patients and extensive tumors of retroperitoneum. METHODS: Five healthy dogs of both sexes were prepared. After general anesthesia and laparotomy, a 1 cm width with 4 cm length defect was arranged on anterior aspect of the infrarenal IVC, subsequently, the anterior aspect of the right diaphragm with 1 cm width and 4 cm length was resected and was anastomosed to cover the defect of the IVC as a patch graft, with the pleural side of the diaphragm facing the luminal aspect and the peritoneal side on the outside. The observation period was 6 weeks. RESULTS: All of the IVCs were macroscopically patent without thrombosis and stenosis. Pathologic assay revealed complete endothelialization of diaphragm. One dog died at the third night of operation without distinct reason. CONCLUSIONS: The diaphragm is an accessible and safe option in the repair and reconstruction of IVC particularly when restrictions exist for the use of prosthetic material in a contaminated space of the abdomen.

Aneurysm of the Internal Carotid Artery Misdiagnosed as Cervical Paraganglioma; A Case Report and Literature Review.

The aneurysms of the extracranial segment of the internal carotid artery are not common and are associated with severe neurologic deficits. They could be misdiagnosed with several lesion of the cervical region. We herein report a case of internal carotid artery aneurysm misdiagnosed as paraganglioma. A 23-year-old man presented with progressive growing mass in right enlarging mass in the upper part of the neck below the angle of the mandible. The patient underwent surgery by the ear, nose, throat (ENT) surgeon through submandibular approach with impression of paraganglioma but severe pulsatile bleeding was encountered intraoperatively. Two vascular clamps were applied and the patient was transferred to the vascular ward. Computerized tomography (CT) angiogram revealed a huge aneurysm of the internal carotid artery in the extracranial segment with injured wall. After 2 days of medical therapy the patient was transferred to the operating room and the aneurysm was repaired using Dacrons. The patient had an uneventful hospital course and was asymptomatic after 1 year of follow-up. Precise preoperative assessment and evaluation with different modalities should be performed to avoid fatal complications. Surgery is a safe and effective method in experienced hands for repair of such aneurysms.

Inferior Vena Cava Repair Using Serosal Patch of Small Bowel: An Experimental Study.

OBJECTIVE: To evaluate the feasibility and results of using serosal patch of small bowel for repair and replacement of inferior vena cava (IVC) after resection of a part of infra-renal IVC in an animal model, as it may be encountered in extensive tumors of retroperitoneal and trauma patients. METHODS: Five healthy sheep of both sexes were prepared. After general anesthesia and laparotomy, a defect with 1 cm width and 4cm length was made on anterior aspect of infra-renal IVC, and then an adjacent loop of small bowel was brought and sutured continuously to cover the defect of IVC as a patch graft. The observation period was two months. RESULTS: Three of five IVCs were macroscopically patent without stenosis and thrombosis. Pathologic assay revealed complete endothelialization of serosal surface of the patch of small bowel loop. One of IVCs was completely occluded in gross evaluation and fibrous formation in pathologist review. The sheep had no sign of venous hypertension and edema of limbs. One sheep died at the night of first operation due to internal bleeding. CONCLUSION: Serosal patch of small bowel is an accessible and feasible alternative in repair and reconstruction of IVC especially when there is restriction for use of prosthetic material in a contaminated space of abdomen.

Lymphaticoperitoneal and Lymphaticopleural Shunting to Treat Lymphedema; a New Therapeutic Approach.

Lymphedema is a common and progressive disease which causes deterioration of the quality of life of the patients, and still, there is no gold standard therapeutic option. In this article, we discuss about our new approach to deal with management of lymphedema which is lymphatic drainage by a subcutaneous channel which is designed as lymphaticoperitoneal and lymphaticopleural shunts for lower and upper extremity lymphedema, respectively.

Chronic Long Standing Shoulder Pain, Caused by Glomus Tumor.

Chronic shoulder pain can be caused by muscle, bone and joint inflammatory and tumoral lesions; however, chronic shoulder pain secondary to benign vascular tumor called glomus tumor is an extremely rare occurrence. To the best of our knowledge less than 15 cases of chronic shoulder pain have been reported secondary to glomus tumor. Herein we report our experience with a young lady who presented with chronic shoulder pain which turned out to be caused by a soft tissue glomus tumor. This case has also been unique because if its large size (about 5 cm in greatest diameter).

Low-level laser therapy: an experimental design for wound management: a case-controlled study in rabbit model.

BACKGROUND: There is a wide array of articles in medical literature for and against the laser effect on wound healing but without discrete effect determination or conclusion. This experimental study aims to evaluate the efficacy of low-level laser therapy on wound healing. MATERIALS AND METHODS: Thirty-four rabbits were randomly enrolled in two groups after creating a full thickness of 3 × 3 cm wound. The intervention group received low density laser exposure (4 J/cm(2)) on days 0, 3 and 6 with diode helium-neon low-intensity laser device (wl = 808 nm) and in control group moist wound dressing applied. Finally, wound-healing process was evaluated by both gross and pathological assessment. RESULTS: Fibrin formation was the same in the two groups (P = 0.4) but epithelialisation was much more in laser group (P = 0.02). Wound inflammation of the laser group was smaller than that of the control groups but statistical significance was not shown (P = 0.09). Although more smooth muscle actin was found in the wounds of the laser group but it was not statistically significant (P = 0.3). Wound diameter showed significant decrease in wound area in laser group (P = 0.003). CONCLUSION: According to our study, it seems that low-level laser therapy accelerates wound healing at least in some phases of healing process. So, we can conclude that our study also shows some hopes for low level laser therapy effect on wound healing at least in animal model.

Use of autologous renal capsule grafts for venous repair.

OBJECTIVE: To evaluate the efficacy of the renal capsule for reconstruction of the inferior vena cava in a canine model. MATERIALS AND METHODS: The present study was conducted on 10 dogs; an oval window (2-8 cm long, mean 6.5 cm) was made in the inferior vena cava and then repaired using the autologous renal capsule patch. The patency and functionality of the graft were assessed macroscopically and microscopically 3 months postoperatively. RESULTS: All the dogs were killed at 3 months, showing excellent patency of the vena cava macroscopically and in the venography. In the microscopic examination, all the patches were completely endothelialized. No evidence of infection or thrombosis was noted. CONCLUSION: A renal capsule patch can be used for reconstruction of the inferior vena cava. Patency appears to be good, and the risk of infection is low. Moreover, this is an accessible material.

Inferior vena cava reconstruction with a flap of parietal peritoneum: an animal study.

BACKGROUND: The development of reconstructive venous surgery has been hampered by the lack of suitable grafts. Patency rates with grafts in the venous system are commonly less satisfactory than in arterial system, mainly due to nonpulsatile flow velocity and the low pressure in veins. Grafting of the inferior vena cava may be necessary in cases of trauma and major tumor surgery involving the vein. Several types of grafts have been evaluated. Reconstruction of the vena cava with autologous vein is so time-consuming and requires extra incisions. Prosthetic material is associated with a higher risk of infection and thrombosis. We, therefore, created an animal model of inferior vena cava reconstruction using a flap of parietal peritoneum. METHODS: A tube, 5 cm in length and 1 cm in diameter, was constructed from the parietal peritoneum of the anterior abdominal wall of ten dogs. It was anastomosed end-to-end as an interposition graft to the inferior vena cava. The observation period was two months. RESULTS: Eight of ten grafts were macroscopically and venographically patent, while the other two were occluded. Eight out of ten specimens (for pathologic examination) which revealed patent lumens were completely endothelialized.No infection or other problems were noted. CONCLUSION: The peritoneum is an accessible and safe substitute for reconstruction of the inferior vena cava.

Tracheal reconstruction by esophageal submuscular tunneling: an experimental study.

BACKGROUND: The problem of how to treat large tracheal lesions remains a challenge in surgery. To reconstruct a long tracheal defect, a safe method other than end-to-end anastomosis is necessary. MATERIALS AND METHODS: In 14 adult cross-breed dogs, a segment of trachea including seven tracheal rings was dissected and resected circumferentially. A submuscular tunnel was induced between mucosal and muscular layers of the adjacent esophagus lying right next to the trachea. An endotracheal tube was inserted between the tracheal rings 2 and 3. Then it was passed cautiously through the esophageal submuscular tunnel and through the distal tracheal segment. The proximal and distal ends of the esophageal tunnel and trachea were approximated and anastamosed. The animals were extubated 10 days after the operation. RESULTS: All dogs tolerated the surgical procedure well. The first two dogs experienced postoperative fever, tracheoesophageal fistula, aspiration pneumonia, and sepsis so hard bony components were omitted from diet. All survived animals were eating and barking well. The submuscular esophageal tunnel was patent in all animals. The new lumen was supported externally with fibrous connective tissue. The tunnelized area was covered completely with pseudostratified ciliated epithelium. CONCLUSION: Due to formation of fibrous tissue between skeletal muscular structures of the neck and the external layer of the tunnelized esophagus, the new airway remained patent. Overall, air tightness, good reepithelialization, and relatively no limitation of esophageal length are the advantages of tracheal reconstruction by submuscular esophageal tunneling. This new method is worthy of further investigation, as it is technically feasible and easy to implement.

Cytologic findings in carotid body tumors.

OBJECTIVE: To describe the cytologic findings in 13 cases of carotid body tumors (CBTs) and discuss the differential diagnoses. STUDY DESIGN: Cytologic smears were obtained from 13 cases of carotid body tumors by fine needle aspiration. All tumors were clinically suspected and later confirmed by arteriography or color Doppler ultrasonography. The cytomorphologic findings are described. RESULTS: The smears revealed hypercellularity, a bloody background, isolated and clusters of round to oval cells with indistinct cytoplasm, reticular chromatin, no prominent nucleoli, giant bare nuclei, anisocytosis, acinar structures and plasmacytoid cells. These findings suggested metastatic tumors. CONCLUSION: The cytologic diagnosis of CBTs is very difficult. The aspiration findings can be easily mistaken for those of metastatic tumors. However, when used with clinical and color Doppler findings, fine needle aspiration plays an important role in the preoperative diagnosis and management of CBTs.