Correção cirúrgica de fístula carotídeo-jugular traumática / Surgical repair of a traumatic carotid-jugular arteriovenous fistula

Resumo Traumatismos cervicais penetrantes podem ser potencialmente fatais. Em cerca de 25% dos casos, há lesão vascular associada, que pode evoluir para fístulas arteriovenosas. Os autores apresentam um caso de correção tardia, por cirurgia aberta, de uma fístula carotídeo-jugular e fazem uma breve revisão sobre o diagnóstico e opções de tratamento dessa condição.

Abstract Penetrating neck injuries can be life threatening. In about 25% of cases there are vascular injuries, which can progress to formation of arteriovenous fistulas. The authors present a case of delayed open surgery to repair a carotid-jugular fistula and briefly review the diagnosis and treatment options for this condition.

Ultrasound guidance for internal jugular vein cannulation in PICU: a randomised controlled trial.

OBJECTIVE: We investigated whether ultrasound guidance was advantageous over the anatomical landmark technique when performed by inexperienced paediatricians. DESIGN: Randomised controlled trial. SETTING: A paediatric intensive care unit of a teaching hospital. PATIENTS: 80 children (aged 28 days to <14 years). INTERVENTIONS: Internal jugular vein cannulation with ultrasound guidance in real time or the anatomical landmark technique. MAIN OUTCOME MEASURES: Success rate, success rate on the first attempt, success rate within three attempts, puncture time, number of attempts required for success and occurrence of complications. RESULTS: We found a higher success rate in the ultrasound guidance than in the control group (95% vs 61%, respectively; p<0.001; relative risk (RR)=0.64, 95% CI (CI) 0.50 to 0.83). Success on the first attempt was seen in 95% and 34% of venous punctures in the US guidance and control groups, respectively (p<0.001; RR=0.35, 95% CI 0.23 to 0.54). Fewer than three attempts were required to achieve success in 95% of patients in the US guidance group but only 44% in the control group (p<0.001; RR=0.46, 95% CI 0.32 to 0.66). Haematomas, inadvertent arterial punctures, the number of attempts and the puncture time were all significantly lower in the ultrasound guidance than in the control group (p<0.015 for all). CONCLUSIONS: Critically ill children may benefit from the ultrasound guidance for internal jugular cannulation, even when the procedure is performed by operators with limited experience. TRIAL REGISTRATION NUMBER: RBR-4t35tk.

Major Intrahepatic Veno-Venous Fistula after Fontan Operation Treated by Transcatheter Implantation of Amplatzer Septal Occluder through Internal Jugular Vein.

Six months after undergoing a Fontan operation, a 7-year-old boy with right atrial isomerism and a single functional ventricle was admitted to our emergency department with cyanosis. Emergency cardiac catheterization revealed a large veno-venous fistula that began in a left hepatic vein, connected to the left accessory hepatic veins, and drained into the common atrium, resulting in desaturation. The fistula was occluded proximally with an Amplatzer septal occluder, with satisfying results; the patient's systemic arterial saturation decreased during his hospital stay. Three weeks after the first intervention, a second procedure was performed to retrieve the first device and to close the fistula distally. Multiple attempts with different types of gooseneck snares and a bioptome catheter failed to retrieve the first device, so a telescopic method was used to re-screw it. Using a Mullins long sheath and delivery sheath, the delivery cable was manipulated to fit into the slot of the end screw, and the cable was rotated gently in a clockwise direction to re-screw the device. Then, another Amplatzer septal occluder was placed at the distal end of the fistula. In conclusion, distal transcatheter occlusion of intrahepatic veno-venous fistulas might lead to better clinical outcomes in selected patients. Amplatzer septal occluder device can be retrieve without any complication within three weeks.

Major intrahepatic veno-venous fistula after fontan operation treated by transcatheter implantation of amplatzer septal occluder through internal jugular vein

Abstract Six months after undergoing a Fontan operation, a 7-year-old boy with right atrial isomerism and a single functional ventricle was admitted to our emergency department with cyanosis. Emergency cardiac catheterization revealed a large veno-venous fistula that began in a left hepatic vein, connected to the left accessory hepatic veins, and drained into the common atrium, resulting in desaturation. The fistula was occluded proximally with an Amplatzer septal occluder, with satisfying results; the patient's systemic arterial saturation decreased during his hospital stay. Three weeks after the first intervention, a second procedure was performed to retrieve the first device and to close the fistula distally. Multiple attempts with different types of gooseneck snares and a bioptome catheter failed to retrieve the first device, so a telescopic method was used to re-screw it. Using a Mullins long sheath and delivery sheath, the delivery cable was manipulated to fit into the slot of the end screw, and the cable was rotated gently in a clockwise direction to re-screw the device. Then, another Amplatzer septal occluder was placed at the distal end of the fistula. In conclusion, distal transcatheter occlusion of intrahepatic veno-venous fistulas might lead to better clinical outcomes in selected patients. Amplatzer septal occluder device can be retrieve without any complication within three weeks.

Face transplantation in rats. Reproducibility of the experimental model in Brazil.

PURPOSE: To investigate the reproducibility of the experimental model of face allotransplantation in rats in Brazil. METHODS: Eighteen rats were operated, nine-nine donors recipients. Animals underwent transplantation of the left hemiface, with periorbital and scalp. Transplants were made from donor Wistar rats to recipients Lewis rats. Flaps were based on the common carotid artery and the external jugular vein of the donor animal and the anastomosis in the recipient area was performed in common carotid artery (end-to-side) and in external jugular vein (end-to-end). RESULTS: Of the nine recipient animals operated, six survived and three progressed to death in the first days after surgery (survival rate = 67%). The mean time of the procedure was 252 minutes and the mean time of flap ischemia was 95 minutes. The five surviving animals were sacrificed at 14 days, in good general condition and without signs of tissue rejection. CONCLUSIONS: The experimental model of face allotransplantation in rats is reproducible in our midst. Duration of surgery, time of flap ischemia, animal survival rate and complications observed were similar to those described in the literature.

Face transplantation in rats. Reproducibility of the experimental model in Brazil

PURPOSE: To investigate the reproducibility of the experimental model of face allotransplantation in rats in Brazil. METHODS: Eighteen rats were operated, nine-nine donors recipients. Animals underwent transplantation of the left hemiface, with periorbital and scalp. Transplants were made from donor Wistar rats to recipients Lewis rats. Flaps were based on the common carotid artery and the external jugular vein of the donor animal and the anastomosis in the recipient area was performed in common carotid artery (end-to-side) and in external jugular vein (end-to-end). RESULTS: Of the nine recipient animals operated, six survived and three progressed to death in the first days after surgery (survival rate = 67%). The mean time of the procedure was 252 minutes and the mean time of flap ischemia was 95 minutes. The five surviving animals were sacrificed at 14 days, in good general condition and without signs of tissue rejection. CONCLUSIONS: The experimental model of face allotransplantation in rats is reproducible in our midst. Duration of surgery, time of flap ischemia, animal survival rate and complications observed were similar to those described in the literature. .

Correction of carotid-jugular traumatic fistula using a bovine pericardial patch / Correção de fístula traumática carotídeo-jugular com pericárdio bovino

Carotid-jugular fistulae are rare, but habitually cause morbidity and mortality. They are often linked with penetrating trauma, primarily caused by gunshots. This report describes the case of a patient who was the victim of a gunshot wound to the left cervical area, provoking a carotid-jugular arteriovenous fistula and occlusion of the common carotid artery. The fistula was corrected by ligature of the internal jugular vein and arteriorrhaphy of the left common carotid artery with a bovine pericardium patch.

A fístula carotídeo-jugular é de ocorrência rara, porém habitualmente causa morbimortalidade. Está associada frequentemente a trauma penetrante, principalmente em razão de lesão por projétil de arma de fogo. Relata-se o caso de um paciente vítima de lesão por projétil de arma de fogo na região cervical esquerda, o que provocou fístula arteriovenosa carotídeo-jugular com oclusão da artéria carótida comum. Foi realizada correção da fístula com ligadura da veia jugular interna e arteriorrafia com remendo de pericárdio bovino na artéria carótida comum esquerda.

Neovascularization after surgical exposure of rat external jugular vein endothelium.

PURPOSE: To investigate the neovascularization after exposure of the external jugular venous endothelium in an experimental model. METHODS: The sample was composed of 60 male rats of Wistar OUT B breed provided by animal colony of the Medicine College of Juazeiro do Norte, weighing 250 to 350 g, aged 90-120 days. Randomized study in OUT B Wistar rats, open, with 60 days duration. The animals were distributed into three groups of 20 specimens and were subjected to the following: Group 1: neck incision with dissection, ligation and section of the external jugular vein. Group 2: neck incision with dissection and ligation of the external jugular vein. Group 3: cervicotomy without dissection of the external jugular vein without ligation or section. The animals were sacrificed, half of them in 30 days and the other half within 60 days. The material in block harvested from the operated site were sectioned and stained for immunohistochemistry with CD34 marker. RESULTS: Neovascularization occurred with level of significance when compared group 1 to group 3 at 30 days (p=0.0076) and the same occurred at 60 days (p=0.0001) (Newman-Keuls test). CONCLUSION: The group with exposure of the venous endothelium showed a significant increase of neovascularization when compared with other groups.

Neovascularization after surgical exposure of rat external jugular vein endothelium

PURPOSE: To investigate the neovascularization after exposure of the external jugular venous endothelium in an experimental model. METHODS: The sample was composed of 60 male rats of Wistar OUT B breed provided by animal colony of the Medicine College of Juazeiro do Norte, weighing 250 to 350g, aged 90-120 days. Randomized study in OUT B Wistar rats, open, with 60 days duration. The animals were distributed into three groups of 20 specimens and were subjected to the following: Group 1: neck incision with dissection, ligation and section of the external jugular vein. Group 2: neck incision with dissection and ligation of the external jugular vein. Group 3: cervicotomy without dissection of the external jugular vein without ligation or section. The animals were sacrificed, half of them in 30 days and the other half within 60 days. The material in block harvested from the operated site were sectioned and stained for immunohistochemistry with CD34 marker. RESULTS: Neovascularization occurred with level of significance when compared group 1 to group 3 at 30 days (p=0.0076) and the same occurred at 60 days (p=0.0001) (Newman-Keuls test). CONCLUSION: The group with exposure of the venous endothelium showed a significant increase of neovascularization when compared with other groups.

Cefalea como única manifestación de trombosis de la vena yugular interna / Isolated headache as clinical manifestation of jugular vein thrombosis

Introducción: La cefalea como manifestación aislada es una forma inusual de presentarse la trombosis venosa cerebral.Caso clínico: Mujer de 21 años que tres días después de un parto normal desarrolla una cefalea intensa sin otrasmanifestaciones asociadas. El examen general y neurológico era normal. Se realiza una angio–TAC en la que se demuestra trombosis de la vena yugular interna derecha, con permeabilidad de los senos laterales. Fue tratada con warfarina por seis meses. El dolor de cabeza regresó en el curso de pocas semanas y no tuvo complicaciones a largo plazo. Los estudios hematológicos descartaron una trombofilia hereditaria.Conclusiones: Se debe tener presente la posibilidad de trombosis venosa cerebral en todo paciente que se presenta cefalea de inicio reciente, especialmente cuando existen condiciones como el embarazo y puerperio que favorecen su ocurrencia(AU)

Introduction: Isolated headache is an unusual presentation of cerebral vein thrombosis.Case report: A 21 years old woman, after a normal delivery, developed a severe headache without other associated symptoms. Neurologic examination, as well as general examination was normal. CT angiography showed right jugular veinthrombosis. She was treated with warfarin for six months. The headache improves, and she recovered without long term complications. Hematologic study searching for hereditary causes that predispose to thrombosis was unremarkable.Conclusions: Cerebral brain thrombosis must be considered in patients with headache of recent onset, especially ifprothrombotic conditions, like pregnancy, are present(AU)

Variation of the Rex shunt for treating concurrent obstruction of the portal and superior mesenteric veins.

Children with extrahepatic portal vein obstruction can be managed successfully by surgical intervention and should be evaluated for potential meso-Rex bypass. A Rex shunt variation is described to treat portal and superior mesenteric vein thrombosis. This technique uses the internal jugular vein as a conduit between the splenic vein and the left portal vein with splenic preservation.

Distancia a introducir un catéter venoso central al puncionar la vena yugular interna por vía anterior derecha en pacientes pediátricos / Distance measured to introduce a central-venous catheter in internal jugular vein via right anterior in children

La colocación correcta del extremo distal del catéter venoso centrales es de gran importancia para la obtención de información hemodinámica. Objetivo: Determinar la distancia existente desde la piel hasta la unión atriocava según edad, peso y talla e identificar las complicaciones. Método: Se incluyeron en un estudio prospectivo, analítico, descriptivo y observacional 72 pacientes pediátricos programados para cirugía cardiaca electiva previo consentimiento informado y aprobación del Comité de Ética. Posterior a la inducción de la anestesia general se colocó un calzo interescapular de 3-5 cm, la cabeza se colocó en posición central y extendida, Trendelemburg 15 grados. A nivel del cartílago cricoideo se localizó el pulso carotídeo derecho y lateral a este se procedió a puncionar la vena yugular interna. El trocar se dirigió con un ángulo de 45º hacia la mama ipsilateral, se introdujo el catéter por técnica de Seldinger clásica, se midió la distancia en centímetro desde el sitio de inserción hasta la articulación esternoclavicular, se confirmó la posición en la unión atriocava del catéter durante la apertura de la aurícula derecha, se determinó la distancia introducida del catéter según su escala. Las complicaciones se recogieron hasta la entrega del paciente en la terapia intensiva donde se realizó una radiografía de tórax anteroposterior. Resultados: en pacientes menores de 1 año y 10 kg se necesita introducir 6 cm, de 1 a 10 años y peso entre 11 y 50 kg, 8 cm y para mayores de 10 años y 50 kg necesitan solo 10 cm con un bajo índice de complicaciones. Conclusiones: Determinamos la distancia a introducir el catéter en la vena cava superior con pocas complicaciones(AU)

The appropriate placement of distal end of the central venous catheter is very important for the achievement of hemodynamic information. Objective: To determine the distance measured from the skin up to atriocaval joint according to age, weight and height and to identify the complications. Method: In an observational, descriptive, analytical and prospective study were included 72 children programmed for elective cardiac surgery previous informed consent and the approval of Ethical Committee. After induction of general anesthesia a 3-5 cm interscapular wedge was placed, head was in central and outstretched position, Trendelemburg position of 15°. At cricoids cartilage level the right carotid pulse was felt and lateral to it the internal jugular vein was punctured. Trocar was directed with an angle of 45° towards the ipsilateral breast introducing the catheter using the classic Seldinger technique measuring the distance in centimeters from the insertion site up to sternoclavicular joint to confirm the position en the atriocaval joint of the catheter during the opening of the right atrium and to determine the distance of the introduced catheter according to its scale. Complications were registered at arrival of patient to intensive therapy unit obtaining anteroposterior thorax radiography. Results: In patients aged under 1 and weighing 10kg it is necessary to introduce 6 cm, from 1 to 10 years and weighing 11 and 50 kg the distance is of 6 cm and for those over 10 years and weighing 50kg are needed only 10 cm with a low rate of complications. Conclusions: Distance to introduce the catheter into the superior vena cava was determined achieving a low rate of complications(AU)

Safety of a training program for ultrasound-guided internal jugular vein catheterization in critically ill patients.

OBJECTIVES: Evaluate the safety and effectiveness of a training program for performing ultrasound-guided internal jugular vein cannulation in critically ill patients. METHODS: Cohort prospective study, evaluating adult patients admitted in a teaching intensive care unit (ICU). Catheter placement was performed by an ICU medical resident. The patient's baseline characteristics, vessel's position and operator experience were the evaluated variables. The main outcomes were cannulation success rate and incidence of major complications. RESULTS: A total of 118 consecutive patients were enrolled between May 2008 and November 2009. The success rate of ultrasound guided catheter placement was 90% (106/118), 77% in the first attempt. Major complications occurred in 4% of the cases (n = 5) and were not associated with the analyzed variables. Inability to place the guide wire was the reason for 58% (7/12) of the failures. Operators with more than 15 previous ultrasound guided cannulations had an increased success rate (95% vs. 79%, p = 0.01) and increased failure was related to previous catheterization (26% vs. 7%, p = 0.02). CONCLUSION: Learning ultrasound guidance for IJV vein cannulation was safe and feasible in ICU patients. This process was not associated to complications and better results were achieved across the spectrum of operator experience.

Safety of a training program for ultrasound-guided internal jugular vein catheterization in critically ill patients / Segurança de um programa de treinamento para punção de veia jugular interna guiada por ultrassom em pacientes críticos

OBJECTIVES: Evaluate the safety and effectiveness of a training program for performing ultrasound-guided internal jugular vein cannulation in critically ill patients. METHODS: Cohort prospective study, evaluating adult patients admitted in a teaching intensive care unit (ICU). Catheter placement was performed by an ICU medical resident. The patient's baseline characteristics, vessel's position and operator experience were the evaluated variables. The main outcomes were cannulation success rate and incidence of major complications. RESULTS: A total of 118 consecutive patients were enrolled between May 2008 and November 2009. The success rate of ultrasound guided catheter placement was 90 percent (106/118), 77 percent in the first attempt. Major complications occurred in 4 percent of the cases (n = 5) and were not associated with the analyzed variables. Inability to place the guide wire was the reason for 58 percent (7/12) of the failures. Operators with more than 15 previous ultrasound guided cannulations had an increased success rate (95 percent vs. 79 percent, p = 0.01) and increased failure was related to previous catheterization (26 percent vs. 7 percent, p = 0.02). CONCLUSION: Learning ultrasound guidance for IJV vein cannulation was safe and feasible in ICU patients. This process was not associated to complications and better results were achieved across the spectrum of operator experience.

OBJETIVO: Avaliar a segurança e efetividade de um programa de treinamento para cateterização da veia jugular interna guiada por ultrassom em pacientes críticos. MÉTODOS: Estudo de coorte prospectivo, avaliando pacientes adultos internados em uma unidade de terapia intensiva com programa de ensino. Os médicos residentes do serviço realizaram as punções de veia jugular interna guiadas por ultrassom. Foram avaliadas as características de base dos pacientes, sintopia dos vasos e experiência dos operadores. Os desfechos primários foram a taxa de sucesso da cateterização e a incidência de complicações graves. RESULTADOS: No período entre maio de 2008 e novembro de 2009 foram avaliados 118 pacientes. A taxa de sucesso da punção guiada por ultrassom foi 90 por cento (106/118), 77 por cento dessas na primeira tentativa. Complicações graves ocorreram em 4 por cento dos casos (n = 5) e não foram associadas às variáveis analisadas. Incapacidade de progredir o fio-guia foi a razão de 58 por cento (7/12) das falhas. Operadores com mais de 15 punções guiadas por ultrassom obtiveram uma maior taxa de sucesso (95 por cento vs. 79 por cento, p = 0,01) e pacientes com cateterização prévia apresentaram um maior número de falhas (26 por cento vs. 7 por cento, p = 0,02). CONCLUSÃO: O aprendizado da técnica de punção de veia jugular interna guiada por ultrasssom é seguro e efetivo em pacientes críticos. Este processo não esteve associado a um aumento da taxa de complicações e melhores resultados são obtidos à medida que aumenta a experiência do operador.

Enxerto sintético e biológico, com e sem preenchimento de veia jugular externa, no reparo de nervo periférico em ratos / Syntetic and biological graft, filled with the external jugular vein in the repair of peripheral nerve in rats

Apesar do desenvolvimento da tecnologia envolvendo o campo da regeneração em nervos periféricos, ainda não existe uma técnica para recuperação do tecido nervoso que apresente resultados totalmente satisfatórios, fato que desperta o interesse de vários pesquisadores em todo mundo e representa um desafio para os cirurgiões que realizam procedimentos reconstrutivos e estéticos. Embora o enxerto autólogo de nervo seja a melhor alternativa para a recuperação de nervos periféricos lesados, as técnicas que envolvem o reparo tubular têm alcançado excelentes resultados através da utilização de materiais sintéticos e biológicos, sob a forma de tubos, no reparo de extensos segmentos nervosos. Hoje, através dos avanços da engenharia tecidual, novos materiais estão em desenvolvimento, com o objetivo de aliar características microscópicas às técnicas cirúrgicas existentes. O colágeno, que é sabidamente um elemento promotor da proliferação celular e do reparo tecidual, tem sido amplamente utilizado em estudos de regeneração nervosa. Da mesma maneira, o ácido poli-láctico-poli-glicólico (PLGA), um copolímero sintético, tem apresentado algumas características favoráveis ao processo de regeneração, como biocompatibilidade e propriedades mecânicas adequadas. Com o propósito de facilitar a regeneração nervosa quando ocorre perda tecidual, uma técnica já difundida pode ser destacada: o enxerto de veia invertida, em que a veia jugular externa é utilizada ao avesso, funcionando como um tubo, criando um microambiente para a regeneração nervosa, através da exposição de elementos fundamentais da camada mais externa do vaso (túnica adventícia). Neste trabalho, agregamos como diferencial a utilização de dois tipos de membranas, especialmente desenvolvidas para fins odontológicos, que visam neoformação óssea, em um estudo que visa à regeneração de um nervo periférico misto, o nervo isquiático. As membranas de colágeno e PLGA foram colocadas na região do enxerto, sob a forma de tubo...

Despite the development of technology involved in peripheral nerve regeneration, there is no technique that presents a recovery of the nervous tissue with completely satisfactory results. This fact arouses interest of several researchers around the word. Although the autologous nerve grafting is the current gold standard for the repair of large nerve gaps, over the past decades the development of artificial nerve conduits has therefore been of great interest due to the excellent results achieved. Through the advances in tissue engineering, new materials, synthetic and biological, have been used for construct nerve guides. The collagen is one of the oldest natural polymers used as a biomaterial, and it is known as a promoter of cell proliferation and of tissue repair. In the same way, the synthetic copolymer, poly lactic-co-glycolic acid (PLGA), have been used for nerve regeneration, and it have shown some favorable characteristics to nerve repair such as stability, biocompatibility, and mechanical properties. With the purpose of facilitating the regeneration in large nerve gaps, the inside-out vein graft is a widespread technique, where the vein works as a conduit, and it provides a good microenvironment for axon regeneration through the exposition of some primordial elements of its adventitial layer. In this work, we join as a differential the use of two materials, specially developed for dental purposes, which are normally used to facilitate the osteogenesis, in a nerve regeneration study. We performed the surgical procedures in the sciatic nerve, with two types of membranes (PLGA and collagen), which were used as tubes, in order to promote the regeneration of this nerve. The collagen and PLGA membranes were used with the objective of a recovery in a 10-mm sciatic nerve gap model. These tubular implants were filled with a 5 mm segment of the jugular vein in order to verify the effectiveness of some biological molecules of the adventitia...

Retained catheter: a rare complication associated with totally implantable venous ports.

Totally implantable venous ports are the main access for chemotherapy. The complications associated with these devices occur most frequently over the course of their use. We report two cases of a complication that had only been described in patients with partially implantable catheters for hemodialysis: retention of a catheter fragment within a vessel during port removal. Both patients underwent adjuvant chemotherapy through the port and even after indication of catheter removal because at the end of treatment, they remained with the devices for long periods of time (7 and 8 yrs, respectively). Due to adherence of the catheters along their intravascular portions, complete removal was impossible. The catheters were sectioned and ligated close to the site where it entered the access vein. After 1 yr of follow-up, both patients were asymptomatic and imaging examinations showed the retained catheters. We believe that an implantable port should be removed after appropriate oncological follow-up.

Apoptosis, cell proliferation and modulation of cyclin-dependent kinase inhibitor p21(cip1) in vascular remodelling during vein arterialization in the rat.

Neo-intima development and atherosclerosis limit long-term vein graft use for revascularization of ischaemic tissues. Using a rat model, which is technically less challenging than smaller rodents, we provide evidence that the temporal morphological, cellular, and key molecular events during vein arterialization resemble the human vein graft adaptation. Right jugular vein was surgically connected to carotid artery and observed up to 90 days. Morphometry demonstrated gradual thickening of the medial layer and important formation of neo-intima with deposition of smooth muscle cells (SMC) in the subendothelial layer from day 7 onwards. Transmission electron microscopy showed that SMCs switch from the contractile to synthetic phenotype on day 3 and new elastic lamellae formation occurs from day 7 onwards. Apoptosis markedly increased on day 1, while alpha-actin immunostaining for SMC almost disappeared by day 3. On day 7, cell proliferation reached the highest level and cellular density gradually increased until day 90. The relative magnitude of cellular changes was higher in the intima vs. the media layer (100 vs. 2 times respectively). Cyclin-dependent kinase inhibitors (CDKIs) p27(Kip1) and p16(INKA) remained unchanged, whereas p21(Cip1) was gradually downregulated, reaching the lowest levels by day 7 until day 90. Taken together, these data indicate for the first time that p21(Cip1) is the main CDKI protein modulated during the arterialization process the rat model of vein arterialization that may be useful to identify and validate new targets and interventions to improve the long-term patency of vein grafts.