Pre-selection blade size choice for the microsurgical clipping of cerebral artery aneurysms: A numerical study.

BACKGROUND: Brain strokes comprise the third leading cause of death worldwide. Microsurgical clipping is recognized as being one of the most effective approaches to the treatment of brain aneurysms. The incomplete closure of the distal-side aneurysm neck is the most common cause of the persistent filling of the dome. Since the diameter of the neck increases when the neck of the aneurysm is squeezed closed by the blades of the clip, the blades should be correspondingly longer. This study provided an assessment of whether the presurgical selection of clips using a 3D planning system is feasible in terms of selecting the most suitable clip for aneurysm occlusion. METHODS: The computational model was created based on computer tomography data obtained from nine brain aneurysms. The closing of the aneurysm was provided in two steps. The first the length of the blades used for closing corresponded to the length of the aneurysm neck as confirmed by the radiological measurements. The second the length of the blades was adjusted according to stage one, so as to determine the minimum required for the closure of all the gaps in the interior space of the aneurysm neck. RESULTS: No differences were detected between the radiological measurement of the aneurysm neck size and the measurements obtained from the reconstructed stereolithographic 3D models. It was observed that the size of the aneurysm neck increased following clipping by 40% to 60% of its original size. The larger the aneurysm neck, the greater the deformation of the aneurysm. CONCLUSION: Firstly, the 3D reconstruction of CT/MRI data did not result in any loss of accuracy and the measurement of the neck of the aneurysm was the same for both of the methods employed. The second, and more important, outcome was that the deformation of the neck of the cerebral aneurysm is at least 1.4x greater than its original size. This information is essential in terms of the pre-selection of the size of the clip.

CHIVA for dummies.

BACKGROUND: Sparing the Great Saphenous Vein capital for possible arterial substitution and recurrence decrease may be an alternative to current ablation options for Varicose Veins treatment. Conservative surgery of varicose veins (CHIVA) was suggested in 1988 by Franceschi, by limited veins interruptions in strategic points. However, the method did not diffuse due to the need for high Duplex expertise to determine the procedure in every single patient. METHOD: Evaluation of the literature regarding saphenous sparing, with special reference to CHIVA. RESULT: It has been realized that basic Ultrasound expertise is sufficient for performing GSV conservation. Most of the time, only a few parameters are needed: a junction competence assessment and a re-entry perforator position. CONCLUSION: For achieving the goal of saphenous conservative treatment, a limited phlebectomy and possible Junction interruption (crossotomy) may be a simplified solution.

Pediatric Vascular Surgery: A Review of Cases from a Dedicated Pediatric Vascular Surgery Clinic.

BACKGROUND: The experience in pediatric vascular diseases is limited in the United Kingdom and worldwide due to their rarity and variations in practice. We looked at types of cases presenting to a dedicated pediatric vascular clinic. METHODS: Medical records of children seen in a dedicated pediatric vascular clinic at a tertiary referral service between 2016 and 2022 were reviewed. These patients were either seen for the first time in that clinic or had their appointments as a follow-up after inpatient review or intervention while being under the care of pediatric teams in local hospitals. RESULTS: Fifty-five patients (34 males) were seen aged between 4 months and 17 years (mean 9.5 years). Common presentations were limb length discrepancy secondary to iatrogenic arterial occlusion, follow-up after bypass for trauma, lower limb swelling or discoloration, and varicose veins. Operative procedures included lower limb bypass, angioplasty, ligation of aneurysms, and varicose vein surgery. CONCLUSIONS: Pediatric vascular conditions are uncommon and therefore most vascular surgeons and trainees will have little exposure to such cases. Intervention is needed for arterial injury secondary to penetrating or iatrogenic trauma. A national registry is required for these rare cases to gain prospective data that can help build up more evidence for educational purposes and to establish guidelines.

Venous vascular reconstruction of a robotically procured right kidney with two renal veins transplanted into a pediatric recipient.

BACKGROUND: Right versus left kidney donor nephrectomy remains a controversial topic in renal transplantation given the increased incidence of right kidney vascular anomalies and associated venous thrombosis. We present the case of a 3-year-old pediatric recipient with urethral atresia and end-stage kidney disease who received a robotically procured living donor right pelvic kidney with two short same-size renal veins and a short ureter. METHODS: We utilized a completely deceased iliac vein system (common iliac vein with both external and internal veins) to extend the two renal veins. Due to the distance between both renal veins, the external iliac vein was anastomosed to the upper hilum renal vein, and the internal iliac vein was anastomosed to the lower hilum renal vein. The donor's short ureter was anastomosed to the recipient's ureter end-to-side. RESULTS: The patient had immediate graft function and there were no post-operative complications. Renal ultrasound was unremarkable at 48 hours post-transplant. Serum creatinine was 0.5 mg/dL at 3 months post-transplant. CONCLUSION: We demonstrate the successful transplantation of a robotically procured right pelvic donor kidney with two short renal veins using a deceased donor iliac vein system for venous reconstruction without increasing technical complications. This technique of venous reconstruction can be used in right kidneys with similar anatomical variations without affecting graft function.

Endoscopic Pedicle Saphenous Vein Graft Harvesting.

The excellent long-term patency of no-touch (NT) saphenous vein grafts (SVGs) makes the grafts very attractive for coronary artery bypass grafting; however, NT-SVG harvesting has a greater incidence of wound complications than conventional methods. Since 2009, we have performed endoscopic vein harvesting (EVH) in our department with very few major wound complications. Because NT-SVG harvesting is expected to provide long-term patency, if performed with EVH, the incidence of wound complications will be reduced. Thus, we began performing endoscopic pedicle SVG harvesting (Pedicle-EVH) in March 2019. Herein, we report the early results obtained using our current Pedicle-EVH procedure. No major wound complications were reported, and the early results, including patency, were satisfactory. To harvest the pedicle SVG, however, we used a different method than the NT-SVG procedure, so careful monitoring will be needed to assess long-term outcomes.

Improved precise guidewire delivery of a cardiovascular interventional surgery robot based on admittance control.

PURPOSE: The development of cardiovascular interventional surgery robots can realize master-slave interventional operations, which will effectively solve the problem of surgeons being injured by X-ray radiation. The delivery accuracy and safety of interventional instruments such as guidewire are the most important issues in the development of robotic systems. Most of the current control methods are position control or force feedback control, which cannot take into account delivery accuracy and safety. METHODS: A cardiovascular interventional surgery robotic system integrated force sensors is developed. A novel force/position controller, which includes a radial basis function neural networks-based inner loop position controller and a force-based admittance outer loop controller, is proposed. Furthermore, a series of simulations and vascular model experiments are carried out to demonstrate the feasibility and accuracy of the proposed controller. RESULTS: The designed cardiovascular interventional robot is flexible to enter the target vessel branch. Experimental results indicate that the proposed controller can effectively improve the delivery accuracy of the guidewire and reduce the contact force with the vessel wall. CONCLUSIONS: The proposed controller based on radial basis function neural network and admittance control is effective in improving delivery accuracy and reducing contact force. The algorithm needs to be further validated in vivo experiments.

Comparison of manual compression, Z-stitch, and suture-mediated vascular closure device techniques in dogs undergoing percutaneous transvenous intervention.

INTRODUCTION/OBJECTIVES: Manual compression has been standard of care for maintaining hemostasis after percutaneous endovascular intervention, but can be time-consuming and associated with vascular complications. Alternative closure methods include the figure-of-eight suture (Z-stitch) and vascular closure device (VCD) techniques. We hypothesized that compared to manual compression, Z-stitch and VCD would significantly reduce time-to-hemostasis after transvenous access, and the proportion of dogs with vascular patency would not differ significantly among treatments. ANIMALS: Forty-six client-owned dogs undergoing percutaneous transvenous interventional procedures. MATERIALS AND METHODS: Dogs with vessel diameter <5 mm were randomized to undergo manual compression or Z-stitch, while those with vessel diameter ≥5 mm were randomized to undergo manual compression, Z-stitch, or VCD. Time-to-hemostasis, bleeding scores, presence of vascular patency one day and two to three months post-procedure, and complications were recorded. Data are presented as median (95% confidence interval). RESULTS: In all 46 dogs, the right external jugular vein was used. Time-to-hemostasis was significantly shorter in the Z-stitch (2.1 [1.8-2.9] minutes) compared to VCD (8.6 [6.1-11.8] minutes; P<0.001) and manual compression (10.0 [10.0-20.0] minutes; P<0.001) groups. Time-to-hemostasis was significantly shorter in the VCD vs. manual compression (P=0.027) group. Bleeding scores were significantly greater at 5 and 10 min (P<0.001 and 0.013, respectively) in manual compression, compared to Z-stitch group. There was no difference in the proportion of dogs with vascular patency between groups (P=0.59). CONCLUSIONS: Z-stitch and VCD are effective venous hemostasis methods after percutaneous transvenous intervention, with Z-stitch providing the most rapid time-to-hemostasis. Both Z-stitch and VCD techniques have low complication rates and effectively maintain vascular patency.

[Research Progress and Prospect Analysis of Vascular Interventional Surgical Robot].

Vascular interventional surgery is an important means to treat cardiovascular and cerebrovascular diseases, but the particularity of its working environment will bring greater radiation threat to doctors. Vascular interventional surgery robots can effectively improve the working environment of doctors and can provide more stable operations, improve the success rate of surgery. This study mainly introduces the current research status, key technologies, and future application of vascular interventional surgical robots.

A Novel Technique of No-Touch Endoscopic Saphenous Vein Harvesting.

No-touch saphenous vein harvesting is considered an ideal procedure for harvesting good-quality veins, whereas endoscopic vein harvesting (EVH) is considered ideal for decreasing wound complications. The no-touch EVH (NT-EVH) technique, which was developed in 2018, is one of the best vein-harvesting procedures. We have improved this method in several aspects since our initial experience. Herein, we present the details of this technique.

Comparison of the efficacy and safety of ultrasound-guided CHIVA and traditional HLS in the treatment of varicose veins of lower extremities - a meta-analysis.

OBJECTIVE: Systematic evaluation of the efficacy and safety of conservative hemodynamic cure for venous insufficiency (CHIVA) compared with high ligation and stripping (HLS) in the treatment of varicose veins of lower extremities. METHODS: We conducted a systematic literature search and compared the randomized controlled trial and retrospective cohort study of CHIVA and HLS in the treatment of varicose veins of lower extremities in several databases, including China National Knowledge Infrastructure, Wanfang database, cqvip datebase, PubMed, Cochrane library and EMBASE, to identify articles that might meet the criteria. Meta-analysis was performed using Revman 5.3 and Stata 13.0 software. RESULTS: This Meta-analysis included a total of 14 research articles. This meta-analysis shows that CHIVA requires shorter operation time than HLS [mean difference (MD) = -13.57, 95% confidence interval (CI) (-21.05, -6.10), P = .0004]. There is less blood loss with CHIVA surgery [MD = -21.72, 95% CI (-30.35, -13.09), P < .00001]. The number of incisions made by the CHIVA technique is less [MD = -3.67, 95% CI (-4.03, -3.31), P < .00001]. Patients who underwent CHIVA had a shorter hospital stay [MD = -3.40, 95% CI (-4.72, -2.09), P < .00001]. The relapse rate was lower after CHIVA [OR = 0.36, 95% CI (0.18, 0.70), P = .003]. In terms of postoperative complications, CHIVA has a lower total complication rate [MD = 0.26, 95% CI (0.15, 0.46), P < .00001]. The incidence of deep vein thrombosis was lower after CHIVA [MD = 0.23, 95% CI (0.06, 0.92), P = .04]. CHIVA has a lower incidence of sensory disturbance than HLS [OR = 0.39, 95% CI (0.25, 0.60), P < .0001]. CHIVA technique has less nerve injury rate than HLS [OR = 0.11, 95% CI (0.02, 0.62), P = .01]. The incidence of hematoma was lower after CHIVA [OR = 0.48, 95% CI (0.27, 0.87), P = .02]. Among other metrics, the comparison results of the 2 techniques were similar. CONCLUSION: By comparison, it is found that CHIVA has shorter operation time, less blood loss, and fewer surgical incisions. Patients who underwent CHIVA surgery had shorter hospital stays and lower relapse rates. In terms of complications, the incidence of total complications after CHIVA is lower, and the incidence of postoperative deep vein thrombosis, postoperative sensory, nerve injury, and postoperative hematoma is also lower than that of HLS.

[Robot-assisted linear aortofemoral bypass surgery]. / Robot-assistirovannoe lineinoe podvzdoshno-bedrennoe shuntirovanie.

Aortofemoral bypass surgery is still the «gold standard¼ for aortoiliac lesions with excellent results and long-term patency despite improvement of endovascular surgery. Extensive surgical approaches are accompanied by high risk of postoperative complications. Development of minimally invasive surgery and achievements of computerized technologies made a revolution in all surgeries and minimize trauma following complex reconstructive procedures. This also reduces perioperative risks and accelerates recovery. Computerized robotic systems in vascular surgery provide safe complex procedures on aortoiliac segment. We present robot-assisted linear iliofemoral bypass surgery in a 69-year-old patient with chronic arterial insufficiency Fontein grade IV.

The historical course of varicose vein surgery in the Persian medicine.

INTRODUCTION: Dawali (varicose veins) is the disease of chronic dilation of veins. The veins of the legs become dilated and blue due to excessive accumulation of blood. This disease and the effort to identify and treat it has a very long history. The condition may have first been described in the Ebers Papyrus more than 3500 years ago. The present study deals with the turning points and progress of varicose vein surgery since ancient times, emphasizing the innovations of the scholars of the Islamic period. METHODS: The present study is based on searching library documents and database data such as PubMed, Scopus, Science Direct, and search engines such as Google Scholar. In the end, the Prisma flow chart was drawn. RESULTS: Besides diagnosing different varicose veins (legs, thighs, abdomen, uterus, and testes), the scholars of the Islamic period were well-versed in their prevention, etiology, and treatment. In treating varicose veins, these physicians used methods such as cleansing, phlebotomy, compression, leech therapy, and surgery, and some of them were the founders of new treatments. CONCLUSION: The surgical treatment of varicose veins in the past was similar to modern surgical therapies. What distinguishes yesterday's varicose vein surgery from today's surgery is a more advanced tool. There is no denying the remarkable progress in using health principles, treatment techniques, and surgical instruments to facilitate surgery and reduce the disease's complications and recurrence. However, the treatment framework and foundation, such as phlebectomy and compression, were all invented and introduced in the distant past.

Long-term results following atrioventricular septal defect repair.

BACKGROUND: Atrioventricular septal defects (AVSD) represent 4-7% of congenital cardiac malformations. Definitive early repair is favored over prior pulmonary artery banding and delayed definitive repair in many centers. The aim of this study was to analyze long-term outcomes following AVSD repair over a 21-year period. METHODS: A total of 202 consecutive patients underwent surgical AVSD correction between June 1999 and December 2020. Surgery was performed using the double-patch technique. The study data were prospectively collected and retrospectively analyzed. Primary outcomes were In-hospital mortality and overall long-term freedom from reoperation. RESULTS: Median age at operation was 120 days (IQR 94-150), median weight was 5.0 kg (4.2-5.3). None of the patients died within the first 30 postoperative days. In-hospital mortality was 0.5% (1/202 patients). Median follow-up was 57 months (11-121). Overall freedom from reoperation at 5, 10 and 15 years was 91.8%, 86.9% and 86.9%, respectively. CONCLUSION: AVSD repair with the double-patch technique is a safe and effective procedure with good early postoperative outcomes and low long-term reoperation rates.

Ultrahigh-Definition-3-Dimensional Exoscope-Assisted Clipping of a Right Middle Cerebral Artery Unruptured Aneurysm with Indocyanine Green Video Angiography: Operative Video.

Ultrahigh-definition 3-dimensional exoscopes represent an excellent technologic innovation in contemporary neurosurgery. They combine the advantages of operating microscopes and endoscopes, offering excellent magnification and lighting, maintaining a relatively small footprint and optimal ergonomic features.1-5 One of the most interesting employments of exoscopes in neurosurgery is represented by intracranial vascular surgery. Reports in this field are still limited, but recent experience has shown that ultrahigh definition 3-dimensional exoscopes for aneurysm surgery are noninferior to operating microscopes for surgery duration, complication rate, and patient outcomes.6 In addition, many intraoperative techniques such as the indocyanine green videoangiography (ICG-VA) have been successfully implemented to exoscope-based surgery.7 We present herein the case of a 66-year-old woman that came to our attention for the incidental finding of 3 unruptured brain aneurysms. After neurosurgical consultation, the one located at the right middle cerebral artery bifurcation was considered eligible for surgery.8,9 As shown in Video 1, ICG-VA was employed after permanent clipping to allow immediate quality assurance of occlusion and distal vessel integrity. Postoperative course was uneventful, and follow-up examinations demonstrated the complete occlusion of the aneurysm. This report highlights the feasibility of exoscopic-based ICG-VA in vascular neurosurgery, given its ease of use, ergonomics, and excellent quality of vision provided to both surgeons and operating staff.

Pancreaticoduodenectomy with preoperative total embolization of the hepatic arteries (PD-HAE)-a novel treatment with sacrifice of the hepatic arterial blood supply without the need for arterial reconstruction.

PURPOSE: Tumors with involvement of common hepatic and gastroduodenal arteries (CHA and GDA) or GDA and the proper hepatic artery (PHA) are traditionally considered nonresectable. We have devised a new procedure that includes pancreaticoduodenectomy with preoperative hepatic artery embolization (PD-HAE) to facilitate an R0 resection of tumors involving the hepatic arteries without vascular anastomoses and complete sacrifice of normal hepatic arterial blood supply. METHODS: To allow resection of the hepatic arteries, preoperative embolization of the PHA was performed to induce an increased collateral arterial blood flow from the periphery of the liver, far from the hepatic hilum 10-14 days prior to the operation. Between May 1, 2017 and December 31, 2019, eight patients with ductal adenocarcinoma were operated with the PD-HAE procedure. RESULTS: The embolizations were uneventful apart from a transient marginal elevation of alanine aminotransferase in three patients. All patients had N disease with perineural invasion of tumor cells around the adventitia of the artery and severe perivascular inflammation. An R0 resection (> 1.0 mm to all resection margins) was obtained in six patients (75%). Mean hospital stay was 12 days. Median survival was 23 months (95% CI: 19.5-26.5 months). Six patients (75%) are still alive 11 to 36 months after the operation. There was perioperative fatality, and morbidity was comparable to standard pancreaticoduodenectomy. CONCLUSION: PD-HAE is a safe procedure and may provide the opportunity for curative resection in otherwise unresectable patients. However, larger studies are needed to evaluate this procedure.

Arterialized Vein Bypass Graft Recipient Vessel in Free Tissue Transfer Covering Diabetic Foot Ulcers Complicated by Critical Limb Ischemia.

ABSTRACT: Limb salvage options are limited in diabetic patients with critical limb ischemia. Soft tissue coverage remains technically demanding with limited recipient vessels for free tissue transfer. These factors make revascularization alone challenging. When open bypass revascularization is possible, venous bypass graft is optimal and functions as a recipient vessel for staged free tissue transfer.The authors present 2 cases using a combination approach of staged venous bypass graft revascularization followed by free tissue transfer with anastomosis to the venous bypass graft resulting in successful limb preservation.Free tissue transfer to a native vessel has limited application in severe peripheral vascular disease patients because early vascular compromise threatens flap survival. In both presented cases, venous bypass graft alone was insufficient to treat their nonhealing wounds, and preoperative angiogram revealed dismal options for free tissue transfer reconstruction. However, previous venous bypass graft provided an operable vessel for free tissue transfer anastomosis. The combination of venous bypass graft and free tissue transfer proved to be ideal for successful limb preservation by providing vascularized tissue to previously ischemic angiosomes, ensuring optimal wound healing capacity. Venous bypass graft is advantageous to native arterial grafts, and its combination with free tissue transfer likely increases graft patency and flap survival. We demonstrate that end-to-side anastomosis to a venous bypass graft is a viable option in these highly comorbid patients with favorable flap outcomes.

Preoperative Rehearsal Sketch for Cerebral Aneurysm Clipping Improves the Accuracy and the Safety of the Surgical Procedure.

OBJECTIVE: With advances in endovascular therapy, the number of cerebral aneurysm clippings has been decreasing. However, some patients are indicated for clipping surgeries. In such circumstances, preoperative simulation is important for the safety and educational aspects of the operation. Herein, we introduce a simulation method using the preoperative rehearsal sketch and report its applicability. METHODS: We compared the preoperative rehearsal sketch with the surgical view for all patients who underwent cerebral aneurysm clipping by neurosurgeons below the seventh grade between April 2019 and September 2022 in our facility. The aneurysm, running of parent and branched arteries, perforators, veins, and clip working were evaluated by senior doctors and scored as follows: correct, 2; partially correct, 1; incorrect, 0; and total score, 12. We retrospectively evaluated the relationship between these scores and postoperative perforator infarctions and, in addition, compared that between simulated and not simulated cases. RESULTS: In the simulated cases, the total scores did not correlate with perforator infarctions, but assessments of the aneurysm, perforators, and clip working affected the total score (P = 0.039, 0.014, and 0.049, respectively). Moreover, perforator infarctions were significantly less in the simulated cases (6.3% vs. 38.5%; P = 0.03). CONCLUSIONS: Precise interpretations of preoperative images and considerations of three-dimensional images are imperative to perform safe and accurate surgeries using preoperative simulation. Although perforators are not always detected preoperatively, it is possible to presume in the surgical view using anatomic knowledge. Therefore, drawing the preoperative rehearsal sketch improves the safety of surgical procedure.

Rural general surgeon confidence with managing vascular emergencies: A national survey.

OBJECTIVE(S): Life and limb threatening vascular emergencies often present to rural hospitals where only general surgery services are available. It is known that Australian rural general surgical centres encounter 10-20 emergency vascular surgery procedures annually. This study aimed to assess rural general surgeons' confidence managing emergent vascular procedures. SETTING, PARTICIPANTS AND DESIGN: A survey was distributed to Australian rural general surgeons to determine their confidence (Yes/No) in performing emergent vascular procedures including limb revascularisation, revising arterio-venous (AV) fistulas, open repair of ruptured abdominal aortic aneurysm (AAA), superior mesenteric artery (SMA)/coeliac embolectomy, limb embolectomy, vascular access catheter insertion and limb amputation (digit, forefoot, below knee and above knee). Confidence level was compared with surgeon demographics and training. Variables were compared using univariate logistic regression. RESULTS: Sixteen per cent (67/410) of all Australian rural general surgeons responded to the survey. Increased age, years since fellowship and training prior to 1995 (when separation of Australian vascular and general surgery occurred) were associated with greater confidence in limb revascularisation, revising AV fistulas, open repair of ruptured AAA, SMA/coeliac embolectomy, and limb embolectomy (p < 0.05). Surgeons who completed >6 months of vascular surgery training were more comfortable with SMA/coeliac embolectomy (49% vs. 17%, p = 0.01) and limb embolectomy (59% vs. 28%, p = 0.02). Confidence in performing limb amputation was similar across surgeon demographics and training (p > 0.05). CONCLUSION: Recently graduated rural general surgeons do not feel confident in managing vascular emergencies. Additional vascular surgery training should be considered as part of general surgical training and rural general surgical fellowships.

Analysis of the postoperative hemodynamic changes in varicose vein surgery related with small saphenous vein reflux.

PURPOSE: To evaluate the postoperative hemodynamic changes in varicose vein surgery related with SSV reflux using APG. METHODS: Totals of 181 limbs and 178 patients who underwent high ligation and stripping (HLS) (87 limbs), radiofrequency ablation (RFA) (43 limbs), or endovenous laser ablation (EVLA) (51 limbs) for SSV reflux from 1995 to 2022 were enrolled. We measured venous volume (VV), venous filling index (VFI), ejection fraction (EF), and residual volume fraction (RVF) preoperatively and at postoperative one and 6 months. RESULTS: Comparing preoperative results to those at postoperative 1 month, the reduction rates of VV, VFI, and RVF were 27, 53, and 31%, while EF increased by 18% (p < 0.001). Comparing preoperative and postoperative 6 month, the reduction rates of VV, VFI, and RVF were 27, 45, and 35%, while EF increased by 27% (p < 0.001). CONCLUSIONS: There were hemodynamic improvement in the lower leg after varicose vein surgery including HLS, RFA, and EVLA.