[Single-Center Experience of Treating Chronic Limb-Threatening Ischemia of Lower Limbs Combined with Diabetes].

Objective: To summarize our hospital's single-center experience of and reflections on the treatment of chronic limb-threatening ischemia (CLTI) of lower limbs combined with diabetes in the past 5 years. Methods: We retrospectively analyzed cases of lower limb CLTI combined with diabetes diagnosed at our hospital from March 2017 to June 2021. The baseline data, surgical information, and follow-up results of the patients were collected. The primary outcome indicator was the patency rate of lower limb target artery within 1 year post-op, and the secondary indicators were the reoperation rate within 1 year post-op and the amputation rate within 1 year post-op. Results: A total of 89 patients with lower limb CLTI combined with diabetes were included in the study. A total of 85 patients underwent percutaneous transluminal angioplasty and the operation of 7 patients ended in failure, with the operation success rate reaching 91.76% (78/85). Three patients underwent femoral popliteal artery bypass grafting with artificial blood vessels and one patient underwent iliac femoral artery bypass grafting with artificial blood vessels, with the success rate of the operations reachign 100% (4/4). Among 78 patients who successfully underwent percutaneous transluminal angioplasty, the median follow-up time was 33 months (13, 64). Two patients died within one year after operation, with the post-op one-year survival rate being 97.44% (76/78). The post-op 1-year reoperation rate was 19.23% (15/78), the 1-year target vascular patency rate (deaths not included) was 85.53% (65/76), and the 1-year amputation rate was 3.85% (3/78). Among the patients who underwent bypass surgery, the follow-up period was 13-48 months. No thrombosis in or re-occlusion of the artificial blood vessels were observed during the follow-up period, and the artificial blood vessels remained unoccluded. Conclusion: Transluminal angioplasty has a relatively ideal rate of postoperative vascular patency. In addition, it is a minimally invasive procedure involving low perioperative risks and is performed under local anesthesia. Therefore, it can be used as the preferred treatment for patients with CLTI. On the other hand, bypass surgery has good long-term patency rate, but it involves higher perioperative risks and the procedure is more invasive. Therefore, bypass surgery can be used as an alternative when transluminal angioplasty ends in failure.

Multiple Splenic Artery Aneurysms: A Case Report and Review of the Literature.

Background: Multiple splenic artery aneurysms (MSAAs) are rare and there are few reports about their treatment. We herein present a rare case of MSAAs treated with splenectomy combined with endovascular embolization. Methods: A 51-year-old female patient was incidentally diagnosed with MSAAs. Splenectomy combined with endovascular embolization was the chosen treatment. Outcomes: The patient recovered uneventfully and was discharged from the hospital 5 days after splenectomy. The patient has been doing well during the 27-months of follow-up. Conclusion: Combined with the experience of the previous literature, we think splenectomy combined with endovascular embolization is a safe, reliable and minimally invasive treatment for some selected multiple SAAs, depending on several patient parameters, such as the age, sex, aneurysm dimension, aneurysm location, complications, and severity of the clinical findings.

Risk Factors for Preoperative Anxiety and Depression in Patients Scheduled for Abdominal Aortic Aneurysm Repair.

BACKGROUND: Perioperative emotional disorders of patients underwent abdominal aortic aneurysm (AAA) repair is an emerging area of study, and preoperative mental distress of those patients remains poorly understood. The aim of this study was to investigate the prevalence and identify the risk factors of preoperative anxiety and depression in patients scheduled for AAA repair. METHODS: A total of 189 patients who underwent elective AAA repair between 2015 and 2016 were included in this study. These patients were preoperatively evaluated by Hospital Anxiety and Depression Scale (HADS). Demographics and anxiety and depression scores of the patients were documented. Logistic regression was used to identify the independent risk factors of preoperative anxiety and depression. RESULTS: A total of 150 AAA patients were included in final analysis. Of these 150 patients, 44 patients (29.3%) had borderline anxiety or clinical anxiety, and 42 patients (28.0%) were found to have borderline or clinical depression. Female (odds ratio [OR]: 2.81, 95% confidence interval [CI]: 1.08-7.26), the American Society of Anesthesiologists (ASA) Grade 3/4 (OR: 4.34, 95% CI: 1.13-16.68), higher education (OR: 1.44, 95% CI: 1.02-2.04), and abdominal or back pain (OR: 3.08, 95% CI: 1.20-7.87) were identified as significant independent risk factors of abnormal HADS-anxiety in overall patients; and higher level of education (OR: 1.87, 95% CI: 1.16-3.01) was predictive of anxiety in patients planned for endovascular aortic repair. Besides, higher body mass index (BMI) (OR: 1.18, 95% CI: 1.04-1.33) and abdominal or back pain (OR: 3.93, 95% CI: 1.70-9.11) were predictive of abnormal preoperative HADS-depression in overall patients. CONCLUSION: As for patients scheduled for AAA repair, female, higher ASA, higher level of education, and symptom may be independent risk factors for preoperative anxiety, and symptom and higher BMI may predict preoperative depression.

[Two Methods of Internal Iliac Artery Exclusion in Endovascular Aorta Repair: a Middle-long Term Follow-up Study].

OBJECTIVE: To compare the middle and long term results of two internal iliac artery exclusionmethods (with or without coils) in endovascular aorta repair (EVAR). METHODS: Clinical data of patients who underwent EVAR from January 2006 to December 2013 were analyzed retrospectively. The participants were divided into two group: coils were not used in Group A, but were used in Group B. The patients were followed up from June 2006 to June 2014. RESULTS: A total of 137 patients (74 in Group A, 63 in Group B) were included in this study, with a mean age of 71. 6 years. The majority (124) of participants were men. Postoperative 30-day mortality of the participants was 0. 73%. None of the participants developed pelvic and spinal ischemia. Claudication appeared in 9 patients (3 in Group A and 6 in Group B). Ischemia in lower extremity happened in 5 patients (2 in Group A and 3 in Group B). Gluteal sore was reported by 5 patients (1 in Group A and 4 in Group B). One patient from Group B developed gluteal skin necrosis. No statistical difference in ischemia and stent occlusion was found between the two groups (P=0. 301, P=0. 108). However, patients in Group B stayed in hospitals longer (P<0. 001) than those in group A. One patient in Group B developed severe ischemic complication: skin and gluteus necrosis. CONCLUSION: Internal iliac artery exclusions with and without coilsresult in similar middle and long term outcomes measured by ischemic complications.

Interventional Therapy for Infective Pseudoaneurysm is a Hope for a Patient in an Undeveloped Area.

Patient, a 59-year-old male coming from an undeveloped area of Sichuan Province, China, was admitted because of chest pain for one month. Compute tomography angiography showed descending aorta pseudoaneurysm at the level of the 6th thoracic vertebra (T6). History of bone tuberculosis and tuberculosis DNA test had confirmed diagnosis of tuberculosis. Interventional surgery was performed 3 days after admission. A covered stent (Medtronic TF 3030C200EE) was deployed slowly and accurately. Digital subtraction angiography showed that the pseudoaneurysm was isolated successfully and completely. The chest pain syndrome was relieved considerably. On the day after surgery, the patient was discharged. Fourteen months later, a recent CT revealed that the stent was in the right place and fluent and no infective clue was detected. The patient did not have any discomfort. Interventional therapy for infective pseudoaneurysm still has long promising prognosis. At the same time, anti-infection therapy is also essential.

Unusual case of digestive hemorrhage: celiac axis-portal vein arteriovenous fistula.

A case of intractable upper gastrointestinal-hemorrhage was reported in a patient with portal hypertension caused by an arterioportal fistula (APF), namely, celiac axis-portal vein arteriovenous fistula. Portal hypertension caused by extrahepatic-APFs is extremely rare. Trauma, malignancy, and hereditary causes are the common etiology of APFs; but were absent in our patient. Our patient represents an unusual case of unexplained APF who presented with portal hypertension and was successfully managed through endovascular aortic repair.

Management of giant posttraumatic abdominal aortic pseudoaneurysm and aortic occlusion using a unique hybrid procedure combining transcatheter device closure and open surgical repair.

Posttraumatic abdominal aortic pseudoaneurysm (AAP) is a rare but life-threating disease. Here, we described a case of posttraumatic AAP with acute abdominal aortic occlusion and its successful treatment using a unique hybrid procedure. An 18-year-old male was referred, with a giant AAP among visceral arteries, which occluded the aorta and left renal artery. An infrequently used ventricular septal device was delivered via femoral access and successfully plugged the tear. Then the isolated pseudoaneurysm was resected through open surgery without major bleeding. At 6 months after operation, the patient was alive without evidence of complications. This hybrid procedure combining transcatheter device closure and open surgery was a successful attempt in the subemergency treatment of posttraumatic AAP.

[Establishment of experimental abdominal aortic aneurysm model in rats].

OBJECTIVE: To establish a new reliable experimental abdominal aortic aneurysm (AAA) rat model that simulates human aneurysms and has high survival rate. METHODS: Twenty-four SD rats were randomly divided equally into two groups (male: female=1: 1). Intraluminal saline infusion was given to rats in group A. Rats in group B were given intraluminal elastase infusion and extraluminal calcium chloride application. The diameter of abdominal aorta was measured and eventually harvested at 4 weeks. Successful AAA formation was defined as a dilation ratio )50%. HE stain was applied to evaluate the histology changes of aorta. RESULTS: Group A had a survival rate, technical success rate and AAA formation rate of 83. 3%, 91. 67%, and 0% respectively, compared with 91. 67%, 100%, and 90. 91% in group B. The AAA formation rate in group B was significantly higher than that in group A (P<0. 05). The dilation ratio during infusion was 50. 82% ±4. 11% in group A and 48. 19% ± 3. 89% in group B. The dilation ratio after infusion was 29. 55% ± 4. 69% in group A and 27. 89% + 4. 28% in group B. The difference of dilation ratio between the two groups was not significant. The post-surgery (28 d) dilation ratio was 27. 89% ± 4. 28%0 in group A and 88. 98% ± 42. 33% in group B (P< 0. 05). Fusiform aneurysms, local adhesion and calcification were found in group B. Rats in group B also had thickening intimal, degenerated matrix in media, loss of elastin fiber, apoptosis of vascular smooth muscle cells and transmural inflammation, none of which was observed in group A. CONCLUSION: With improved operative procedure, intraluminal elastase infusion and extraluminal calcium chloride application can create reliable AAA rat model.

The pre-Kasai procedure in living donor liver transplantation for children with biliary atresia.

BACKGROUND: Biliary atresia (BA) is a major cause of chronic cholestasis, a fatal disorder in infants. This study was undertaken to evaluate the safety and effectiveness of primary living donor liver transplantation (LDLT) in comparison with the traditional first-line treatment, the Kasai procedure. METHODS: We assessed 28 children with BA at age of less than two years (3-21.3 months) who had undergone LDLT in two hospitals in Southwest China during the period of 2008-2011. Eighteen children who had had primary LDLT were included in a primary LDLT group, and ten children who had undergone the Kasai operation in a pre-Kasai group. All patients were followed up after discharge from the hospital. The records of the BA patients and donors were reviewed. RESULTS: The time of follow-up ranged 12-44.5 months with a median of 31 months. The 30-day and 1-year survival rates were 85.7% and 78.6%, respectively. There was no significant difference in the 30-day or 1-year survival between the two groups (83.3% vs 90% and 77.8% vs 80%, P>0.05). The main cause of death was hepatic artery thrombosis. There were more patients with complications who required intensive medical care or re-operation in the pre-Kasai group (8, 80%) than in the primary LDLT group (9, 50%) (P=0.226). But no significant differences were observed in operating time (9.3 vs 8.9 hours, P=0.77), intraoperative blood loss (208.6 vs 197.0 mL, P=0.84) and blood transfusion (105.6 vs 100.0 mL, P=0.91) between the two groups. The durations of ICU and hospital stay in the primary LDLT group and pre-Kasai group were 180.4 vs 157.7 hours (P=0.18) and 27 vs 29 days (P=0.29), respectively. CONCLUSIONS: Primary LDLT is a safe and efficient management for young pediatric patients with BA. Compared with the outcome of LDLT for patients receiving a previous Kasai operation, a similar survival rate and a low rate of re-operation and intensive medical care for patients with BA can be obtained.

[Surgical vascular by-pass operation of lower limb artery occlusion in patients with diabetic foot].

OBJECTIVE: To document the effectiveness and patient experience of surgical treatment for diabetic lower limb arterial occlusion. METHODS: Out of 290 diabetic patients with lower limb arterial occlusion, 69 received by-pass operation because of severe stenosis below the abdominal aorta and severe ulcers in feet from April 2004 to April 2011. We reviewed the experience and outcome of the 69 diabetic patients who underwent surgical operations on lower limb arterial occlusion. RESULTS: 100% initial surgical success was achieved. The morbidity (excluding death) was 12.3% +/- 4.1% and 15.7% +/- 5.1% at 1 year and 3 years after operations, respectively. Five (7.2%) death cases were recorded, which resulted in a survival rate of 94.2% +/- 2.8% and 92.0% +/- 3.5% at 1 year and 3 years after operations, respectively. About 90.6% +/- 3.6% and 87.2% +/- 4.9% of patients had graft patency 1 year and 3 years after operations, respectively; and 6. 5% + 3. 1% had amputations. Four (5. 8%) patients developed graft thrombosis, in which 2 (2.9%) had amputations because of recurrence of thrombosis after thrombectomy. Two (2.9%) patients had amputations because of graft infection accompanied with graft resection operations. One (1.4%) patient received repeated arterialized operation on great saphenous vein because of popliteal artery occlusion, and obtained a good outcome within two years. One (1.4%) patient developed stomas false aneurysm, but the excision of the false aneurysm resulted in a good outcome in four years. CONCLUSION: Detailed pre-operation assessment, optimal selection of surgical procedure and perioperative management can help improve the outcome of diabetes and decrease amputation rate in patients with diabetic lower limb arterial occlusion.

[Surgical treatment of sinus tract in diabetic foot with adjacent pedicle fascia flap and arthrodesis].

OBJECTIVE: To study the therapeutic effect of adjacent pedicle fascia flap filling and arthrodesis in the regional management of sinus tract in diabetic foot. METHODS: From February 2007 to August 2010, 6 patients suffering diabetic foot with sinus tract were included. There were 4 male and 2 female patients, aged 47 to 68 (averaging 58.3 +/- 6.7). One case had the entrance of sinus tract in the heel, and its base located deep in the calcaneus. Three cases had the sinus tract in the vola or dorsum of the foot, in which 1 with a perforating tract connecting the vola and the dorsum. Another 2 cases were in the toes, both located around joints. Under the effective treatments of anti-infection, anti-coagulation and control of blood sugar, blood pressure as well as blood lipid level, the patients were subjected to surgical treatments of sinus tract, the sinuses in the heel, sole and dorsum of the feet were filled up with facial flap, and those in the toes were eliminated using arthrodesis. RESULTS: All the 6 patients received rational debridement. Four patients were treated with adjacent fascia flap filling, the other two were treated with arthrodesis. The sinus tracts healed 14-20 d after surgery in all patients. One patient developed skin necrosis at the edge of the incision in the dorsum of the foot and another whose sinus located in the toe suffered inflammation and exudation. Both patients recovered after dressing replacement, antiseptic therapy and blood sugar regulation for a period of time. CONCLUSION: Appropriately designed pedicle fascia flap can provide satisfactory healing for sinus in the heel, vola and dorsum, and arthrodesis is a safe and effective way for that in the toes. Rational debridement is the key prerequisite for healing of sinus tract in diabetic foot.

[Clinical and pathological characteristics and surgical treatment of carotid body tumor with endocrine activity].

OBJECTIVE: To investigate the clinical and pathological characteristics and surgical treatment of carotid body tumor with endocrine activity (CBT). METHODS: Records of seven CBT patients with endocrine activity (Jan, 1991-Aug, 2011) who underwent surgical excision of tumor were retrospectively reviewed. The operations were performed with the careful peroperative preparation on the control of blood pressure, serum potassium and catecholamine. All the tumors were studied with the methods of HE staining, immunohistochemistry of chromogranin A (CgA) and S-100. RESULTS: All the operations were successfully accomplished and the patients recovered quickly. It was confirmed with pathological examination that all the tumors were CBT, coming from paraganglioma. Tumor cells and sertoli cells were found in HE staining, and all were positive of CgA and S-100. All patients were followed up for 12-60 months and no recurrence was found during the follow up. CONCLUSION: CBT with endocrine activity presents with identifiable clinical and pathological characteristics. The recommended treatment is surgical resection, careful perioperative preparation and care is important to avoid the severe complication due to the endocrine activity of tumor.

[Perioperative outcomes after endovascular versus open repair of abdominal aortic aneurysms: a single center experience].

OBJECTIVE: To evaluate the outcomes of endovascular repair (EVAR) versus open repair (OR) in the patients with abdominal aortic aneurysm (AAA) and compare their perioperative rates of morbidity and mortality. METHODS: The clinical data of 371 AAA patients from January 2006 to January 2011 were collected and analyzed. Endovascular (n = 174) and open (n = 197) repairs were performed. The relevant parameters included preoperative status, intraoperative blood loss, procedure time, intensive care unit (ICU) stay length, ventilatory support time, postoperative fasting time and duration of postoperative hospital stay and anesthesia methods. The perioperative rates of morbidity and mortality were presented. RESULTS: The patients of EVAR group were elder than those of OR group [(72 ± 8) vs (60 ± 14) years old, P = 0.000]. The comorbidity rate of chronic obstructive pulmonary disease (COPD) in EVAR group was higher than that in OR group (31.0% vs 21.8%, P = 0.045). As compared with OR group, the EVAR group had less blood loss [(125 ± 43) vs (858 ± 602) ml, P = 0.000], a lower rate of blood transfusion (0 vs 71.1%, P = 0.000), shorter ICU stay length [(15 ± 5) vs (31 ± 11) h, P = 0.000], shorter postoperative fasting time [(7 ± 4) vs (90 ± 32) h, P = 0.000], shorter procedure time [(146 ± 39) vs (210 ± 24) min, P = 0.000] and shorter ventilatory support time [(90 ± 23) vs (220.0 ± 132.0) min, P = 0.000]. In EVAR group, general (88, 50.6%), epidural (52, 30.0%) and local (34, 19.4%) anesthesia were used. General anesthesia was used for all OR group patients. The duration of postoperative hospital stay was similar in two groups (9.1 ± 2.7) d vs (9.2 ± 2.6) d (P = 0.798). The perioperative complication rate was lower in EVAR group (12.6% vs 27.0%, P = 0.001). And the 30-day mortality rate was 1.15% in EVAR group and 2.0% in OR group. CONCLUSION: Endovascular repair is less-invasive in AAA patients and offers significant advantages over open surgery. Especially it is indicated for those patients non-suitable for open surgery. And a long-term survival rate is expected.

Higher tacrolimus blood concentration is related to hyperlipidemia in living donor liver transplantation recipients.

BACKGROUND: The arrival of tacrolimus has drastically improved AALDLT recipients' survival. However, little data of tacrolimus have been reported concerning its effects on lipid metabolism for AALDLT recipients. AIM: Out aim was to investigate the relationship between tacrolimus blood concentration and lipid metabolism in AALDLT recipients. METHODS: The pre and postoperative data of 77 adult patients receiving AALDLT between 2002 and December 2007 were retrospectively reviewed. The postoperative immune suppressive regimen was prednisone with tacrolimus ± mycophenolate mofetil. Prednisone was withdrawn within the first postoperative month. Blood lipids and tacrolimus concentration were detected at the first, third, and sixth month during follow-up. Episodes of acute rejection were diagnosed based on biopsy. RESULTS: Overall prevalence of post-transplantation hyperlipidemia was 29.9% (23/77) at the sixth postoperative month. The patients were divided into two groups, the hyperlipidemia group and the ortholipidemia group. In the 23 patients with hyperlipidemia, 15 (65%) were hypercholesterolemia, five (22%) were hypertriglyceridemia, and three (13%) patients had both hypercholesterolemia and hypertriglyceridemia. In univariate analysis, only tacrolimus blood concentration at the third and sixth post-transplantation months showed significant difference (8.7 ± 2.1 vs. 6.9 ± 3.2, p = 0.013; 9.2 ± 2.7 vs. 7.3 ± 3.8, p = 0.038, respectively). In multivariate logistic analysis, only two factors appear to be risk factors, namely, tacrolimus blood concentration at the third and sixth post-transplantation months (8.7 ± 2.1 vs. 6.9 ± 3.2, p = 0.043; 9.2 ± 2.7 vs. 7.3 ± 3.8 p = 0.035, respectively). CONCLUSIONS: Higher tacrolimus blood concentration was related to hyperlipidemia at an early postoperative period. This indicates that tacrolimus blood concentration should be controlled as low as possible in the premise that there is no risk of rejection to minimize post-transplant hyperlipidemia after AALDLT.

Quantification and location of Chlamydia pneumoniae-specific antigen in the walls of abdominal aortic aneurysms.

BACKGROUND: To evaluate the prevalence and quantity of Chlamydia pneumoniae-specific antigen in the three layers (intima, media, and adventitia) of abdominal aortic aneurysms (AAAs), so as to further investigate the pathogenesis of AAAs. METHODS: Aortic walls were collected from 20 patients with AAA and 11 healthy organ donors. Immunohistochemistry was used to identify the C pneumoniae-specific antigen, and image analysis system was used to quantify and locate it. RESULTS: The positive rate of C pneumoniae-specific antigen was higher in the AAA group than in the control group (100% vs. 54.54%, p = 0.003), positive intensity decreased from the tunica intima to the adventitia in the AAA group (16.32% ± 2.13%, 14.84% ± 1.80%, and 14.25% ± 1.67%, respectively, p = 0.003). In the control group, positive cells were mainly found in focal lesion areas. CONCLUSION: We have demonstrated the presence and differentiation of C pneumoniae-specific antigen in the three layers of AAAs, which are in accordance with pathology, thus suggesting a pathogenic role of the antigen.

Microsurgical reconstruction of hepatic artery in A-A LDLT: 124 consecutive cases without HAT.

AIM: To retrospectively investigate microsurgical hepatic artery (HA) reconstruction and management of hepatic thrombosis in adult-to-adult living donor liver transplantation (A-A LDLT). METHODS: From January 2001 to September 2009, 182 recipients with end-stage liver disease underwent A-A LDLT. Ten of these patients received dual grafts. The 157 men and 25 women had an age range of 18 to 68 years (mean age, 42 years). Microsurgical techniques and running sutures with back-wall first techniques were performed in all arterial reconstructions under surgical loupes (3.5 x) by a group of vascular surgeons. Intimal dissections were resolved by interposition of the great saphenous vein (GSV) between the donor right hepatic artery (RHA) and recipient common HA (3 cases) or abdominal aorta (AA) (2 cases), by interposition of cryopreserved iliac vessels between the donor RHA and recipient AA (2 cases). RESULTS: In the 58 incipient patients in this series, hepatic arterial thrombosis (HAT) was encountered in 4 patients, and was not observed in 124 consecutive cases (total 192 grafts, major incidence, 2.08%). All cases of HAT were suspected by routine color Doppler ultrasonographic examination and confirmed by contrast-enhanced ultrasound and hepatic angiography. Of these cases of HAT, two occurred on the 1st and 7th d, respectively, following A-A LDLT, and were immediately revascularized with GSV between the graft and recipient AA. HAT in one patient occurred on the 46th postoperative day with no symptoms, and the remaining case of HAT occurred on the 3rd d following A-A LDLT, and was cured by thrombolytic therapy combined with an anticoagulant but died of multiorgan failure on the 36th d after A-A LDLT. No deaths were related to HAT. CONCLUSION: Applying microsurgical techniques and selecting an appropriate anastomotic artery for HA reconstruction are crucial in reducing the high risk of HAT during A-A LDLT.

Potential etiopathogenesis of seventh day syndrome following living donor liver transplantation: ischemia of the graft?

BACKGROUND: Seventh-day syndrome (7DS) is an early serious complication following liver transplantation with a high mortality because of its unknown etiopathogenesis. This study aimed to analyze the potential etiopathogenesis of 7DS. METHODS: A retrospective analysis of 98 consecutive living donor liver transplants performed from 2001 to 2007 at our center revealed that 5 patients had suffered from 7DS; their age, MELD score, portal vein inflow and other parameters were compared with those of the other recipients. RESULTS: The 5 patients showed common features: (a) initial uneventful recovery, and a dramatic rise of serum liver enzyme levels 1 to 2 weeks later; (b) decreased inflow in the portal vein accompanied by augmentation of serum creatinine and urea nitrogen level; and (c) serial liver biopsy findings of apoptosis and ischemic necrosis of hepatocytes. Four of the 5 patients died. Age, waiting time to transplantation, MELD score, operation time, cold ischemic time, portal interceptive time and diameter of the portal vein were not significantly different between the 2 groups, but a difference was found in the flow rate of the portal vein (t=3.234, P<0.001). CONCLUSIONS: The 5 patients suffered from a decreased portal vein inflow, ischemic liver necrosis, and renal failure. Hence, hypoperfusion of the liver graft was considered to be the etiopathogenesis of 7DS, for which, however sufficient evidence is lacking. More studies of 7DS are needed.

Transdiaphragmatic exposure for direct atrioatrial anastomosis in liver transplantation.

BACKGROUND: Liver transplantation in Budd-Chiari syndrome remains controversial; however, some improved techniques lead to better results. We report medium-term follow-up results of liver transplantation with atrioatrial anastomosis for Budd-Chiari syndrome and explore the indications of liver transplantation with atrioatrial anastomosis for patients with end stage liver disease. METHODS: Nine patients (six Budd-Chiari syndromes, one end stage hepatolithiasis, one hepatocellular carcinoma and one incurable alveolar echinococcosis) underwent liver transplantation with atrioatrial anastomosis in West China Hospital of Sichuan University from 1999 to 2006. Eight liver transplants used cadaveric orthotopic livers and one a living donor liver. The operative technique was transdiaphragmatic exposure for direct atrioatrial anastomosis and replacement of inferior vena cava by cryopreserved vena cava graft with the help of venovenous bypass. RESULTS: All liver transplantations were successful. Two patients contracted pulmonary infection and acute rejection took place in another case. With proper treatment, all patients recovered well and had good quality of life. To date, they have been followed up for more than 24 months. The only death followed recurrence of hepatic carcinoma three years after liver transplantation. CONCLUSIONS: Transdiaphragmatic exposure for direct atrioatrial anastomosis and the cryopreserved vena cava graft replacement of inferior vena cava are possible for patients with end stage liver disease thus extending the indications of liver transplantation.