Resectable fusiform internal jugular vein aneurysm with vascular excision and bypass with an 8 mm Maquet graft: A case report.

RATIONALE: Venous aneurysm is a rare vascular disease. Studies reveal that patients with fusiform internal jugular vein aneurysms are not suitable for embolization. PATIENT CONCERNS: Two treatment options are considered, either bypass the aneurysm via stenting or excision of the lesion site and anastomosis using an artificial graft. The advantages of excision bypass include the absence of endoleak and stent migration; however, a larger wound and longer operation time are required for it. DIAGNOSES: Physical examination revealed a swelling in the right neck area. Head and neck computed tomography was performed for the survey. It revealed a 27.22 × 25.07 × 58.17 mm internal jugular fusiform aneurysm. INTERVENTIONS: Vein excision was performed while using hemoclamps to control inflow and outflow, and a graft was anastomosed for bypass using an 8 mm Maquet graft. OUTCOMES: The wound recovery was favorable, with no signs of infection, and the pain was under control. LESSONS: The patient had a contrast-enhanced head and neck computed tomography, and the images efficiently diagnosed a venous aneurysm. This patient had refractory pain, which was a significant indication of the operation. We decided by ourselves on the duration of the interval of following up. We used excision and bypassing with graft, and the result was beneficial.

Transcatheter Arterialization of Deep Veins in Chronic Limb-Threatening Ischemia.

BACKGROUND: Approximately 20% of patients with chronic limb-threatening ischemia have no revascularization options, leading to above-ankle amputation. Transcatheter arterialization of the deep veins is a percutaneous approach that creates an artery-to-vein connection for delivery of oxygenated blood by means of the venous system to the ischemic foot to prevent amputation. METHODS: We conducted a prospective, single-group, multicenter study to evaluate the effect of transcatheter arterialization of the deep veins in patients with nonhealing ulcers and no surgical or endovascular revascularization treatment options. The composite primary end point was amputation-free survival (defined as freedom from above-ankle amputation or death from any cause) at 6 months, as compared with a performance goal of 54%. Secondary end points included limb salvage, wound healing, and technical success of the procedure. RESULTS: We enrolled 105 patients who had chronic limb-threatening ischemia and were of a median age of 70 years (interquartile range, 38 to 89). Of the patients enrolled, 33 (31.4%) were women and 45 (42.8%) were Black, Hispanic, or Latino. Transcatheter arterialization of the deep veins was performed successfully in 104 patients (99.0%). At 6 months, 66.1% of the patients had amputation-free survival. According to Bayesian analysis, the posterior probability that amputation-free survival at 6 months exceeded a performance goal of 54% was 0.993, which exceeded the prespecified threshold of 0.977. Limb salvage (avoidance of above-ankle amputation) was attained in 67 patients (76.0% by Kaplan-Meier analysis). Wounds were completely healed in 16 of 63 patients (25%) and were in the process of healing in 32 of 63 patients (51%). No unanticipated device-related adverse events were reported. CONCLUSIONS: We found that transcatheter arterialization of the deep veins was safe and could be performed successfully in patients with chronic limb-threatening ischemia and no conventional surgical or endovascular revascularization treatment options. (Funded by LimFlow; PROMISE II study ClinicalTrials.gov number, NCT03970538.).

Development of chronic venous disease.

INTRODUCTION: Chronic venous disease is known to gradually worsen in the course of years. However, little clinical data is available. The patient group and methods: We used the set of our patients with completed clinical examination, duplex sonography and photoplethysmography and selected 160 patients examined at our office after 10 and more years. Females represented 79% in the group. The mean age was 54 years (range 18-82 years). Venous varices in lower limbs in the family were reported by 49% patients. Venous sclerotization had been undergone by 6.3% and venous surgery by 10.6% patients. The mean body mass index was 27. We used CEAP classification. The clinical class C1 included 50 patients, C2 included 81, C3 included 15 and C4 included 14 patients. Regurgitation in superficial veins was found in 43%. The mean venous return time after physical activity was 24.5 s. RESULTS: The last examination was performed after 13 years on average (range 10-28 years). Deterioration of the clinical condition and progression to a higher class were observed in 36% patients in class C1, in 23.5% patients in C2, in 13% patients in C3 and in 7% patients in C4. We did not demonstrate any statistically significant effect of the followed parameters on the progression of the disease. CONCLUSION: The progression rate of the disease in our patient group followed at the vascular office for 10 and more years is lower compared to population studies.

Effect of preoperative functional exercise on cephalic vein diameter, anastomotic blood flow, and postoperative complications in patients with arteriovenous internal fistuloplasty.

The purpose of this study was to investigate the effect of preoperative functional exercise on cephalic vein diameter, anastomotic blood flow, and postoperative complications in patients with arteriovenous internal fistuloplasty. A total of 140 patients who underwent arteriovenous fistuloplasty from March 2019 to October 2021 were randomly divided into two groups: intervention group (n=70) and control group (n=70). The control group was treated with routine nursing intervention, while the intervention group was treated with preoperative functional exercise and routine nursing intervention. There was no significant difference in the diameter of cephalic vein between the two groups two weeks before the operation (p=0.742). The diameter of cephalic vein in the intervention group was larger than that in the control group two weeks after the operation (p < 0.001), and the blood flow of anastomotic vein in the intervention group was higher than that in the control group two weeks after the operation (p < 0.001). There was no significant difference in the total prevalence of postoperative complications such as vascular stenosis, thrombosis, and swelling hand syndrome between the intervention group and the control group (P=0.546). The findings show that preoperative functional exercise may increase the diameter and blood flow in the vessels, and improve vascular conditions in patients with arteriovenous fistuloplasty, but may have no effect on postoperative complications.

Linear endovenous energy density (LEED) should always be quoted with the power used in endovenous thermal ablation - results from an in-vitro porcine liver model study.

BACKGROUND: Linear Endovenous Energy Density (LEED) is the energy used per cm of vein in endovenous thermal ablation (EVTA) but does not include time. This study examines the effect of time during EVTA. METHOD: EVTA was performed in a previously validated porcine liver model. LEEDs of 40, 60, 80 and 100 J/cm, using different powers were repeated 5 times each. Thermal spread, tissue carbonisation and device-tissue sticking during treatment were recorded. RESULT: LEED positively correlated to thermal spread and carbonisation of the tissue. Power was correlated with carbonisation but not thermal spread. Pullback had no correlations with thermal spread or carbonisation. Catheter sticking found occurred in powers >= 15 W or LEED >= 80 J/cm. CONCLUSION: LEED is a good measure of EVTA but does not include time. Power, which does include time, correlates with carbonisation and with device-tissue sticking. The power used must be quoted with the LEED.

Radio basilic transposition arteriovenous fistula : An effective but less frequently used haemodialysis vascular access - A Case Report.

Radiobasilic transposition arteriovenous fistula (RBTAVF) is often ignored as an option for haemodialysis access. We present the case of a 57-year-old male patient who presented at the AKUH vascular clinic, Karachi, for the creation of long-term haemodialysis vascular access. He had small-sized forearm cephalic vein (1.5 mm), but reasonable sized basilic vein. He underwent successful RBTAVF. Most of the guidelines recommend brachiocephalic fistula (BCF) as the second choice following radiocephalic AVF. This case recommends the inclusion of RBAVF as the second choice for vascular access in international guidelines, in addition to BCF and BBF.

[Anatomical types and anastomosis methods of concomitant veins of deep inferior epigastric artery].

Objective: To summarize the anatomical types of the concomitant veins of deep inferior epigastric artery and the corresponding choice of anastomosis methods, and to evaluate the indications and safety of various methods. Methods: Between October 2015 and June 2021, 296 female patients received breast reconstruction with autologous free lower abdominal flap, including 154 cases of immediate breast reconstruction and 142 cases of delayed breast reconstruction. The average age of the patients was 36.5 years, ranged from 26 to 62 years. Unilateral free deep inferior epigastric artery perforator flap transplantation was performed in 172 cases, and unilateral free muscle-sparing rectus abdominis myocutaneous flap transplantation was performed in 124 cases. The internal thoracic vessels were selected as the recipient vessels in all cases. The length of vascular pedicle ranged from 9.5 to 13.0 cm, with an average of 11.2 cm. The concomitant veins of deep inferior epigastric artery included three anatomical types: one-branch type in 26 cases (8.8%), two-branch type in 180 cases (60.8%), and Y-shaped structure in 90 cases (30.4%). Anastomosis of inferior epigastric artery was performed with the proximal end of internal thoracic artery, while that of vein should be adjusted according to the diameter, length, wall thickness, and branches of the vein. The specific classification of venous anastomosis included: ① The sole concomitant vein of deep inferior epigastric artery was anastomosed with the internal mammary vein (26 cases); ② The two concomitant veins of deep inferior epigastric artery were anastomosed with the internal mammary vein respectively (151 cases); ③ The larger one of two concomitant veins of deep inferior epigastric artery was anastomosed with the internal mammary vein, and the other one was ligated and discarded (29 cases); ④ The two concomitant veins of deep inferior epigastric artery were Y-shaped, and the common trunk segment was directly anastomosed with the internal mammary vein (31 cases); ⑤ The smaller branch of the concomitant veins of Y-shaped structure was ligated, and the thicker branch was anastomosed with the internal mammary vein (17 cases); ⑥ The concomitant veins of Y-shaped structure were anastomosed with the internal mammary veins respectively (42 cases). Results: Among the patients who underwent venous anastomosis according to scheme ④, 3 cases had venous crisis of flap after operation, of which 1 case was successfully rescued by emergency exploration; the other 2 cases had flap necrosis, of which 1 case survived after being repaired by pedicled latissimus dorsi flap, and 1 case closed the wound directly. Flaps with other venous anastomosis protocols survived completely. All 296 patients were followed up 12-70 months, with an average of 37.5 months. The reconstructed breast has good shape, good elasticity, and no skin flap contracture. The donor site of the flap only left linear scar, and the abdominal wall function was not affected. Conclusion: The method of direct anastomosis of concomitant veins of deep inferior epigastric artery with Y-shaped structure is relatively risky, and the vessels are prone to be twisted and compressed, leading to the occurrence of venous crisis. It can improve the safety of surgery if only one large vein is anastomosed or two veins are separated to anastomose respectively.

Simultaneous bilateral distal venous arterialization between redial artery and cephalic vein in dorsal hand for Raynaud's phenomenon in both hands: A case report.

Raynaud's phenomenon (RP) is characterized by episodic vasospasm in peripheral vessels and ischemia of the fingers. Venous arterialization is thought to induce neovascularization and increased oxygen tension. In this report, we describe a patient with RP in the fingers of both hands in whom venous arterialization achieved an acceptable result in both hands. The patient was a 62-year-old woman with a 10-year history of worsening pain and cold sensation in the tips of the index, middle, ring, and little fingers on both sides. The venous arterialization procedure was performed on both hands simultaneously at the level of the anatomical snuff box between radial artery and cephalic vein in dorsal hand. There was no need for valvectomy in the level of hands. To prevent development of the steal phenomenon in the arterialized veins, the superficial basilic and median veins of the forearm were ligated via 1 cm skin incisions. The pain and cold sensation in the fingertips of both hands remained decreased, and the nonhealing ulcers on the fingertips healed without the need for amputation. The observation period was 14 months, and the surface temperature of the fingers was increased after venous arterialization, as was the temperature of the palm and forearm. There was no problem when administering intravenous infusion into the forearm on either side postoperatively. The case showed venous arterialization was effective for RP without increasing intravenous pressure in the affected limb, and further investigation is necessary.

Treatment of arteriovenous fistula with aneurysm using the forearm branch of the cephalic vein as a candidate vessel: A case report.

BACKGROUND: Arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis patients due to its better patency rates and fewer complications than other access types. However, some complications related to AVF could not be ignored, including swollen hands and an aneurysm. Although a patient could not continue hemodialysis, it might threaten the patient's life if the rupture of the aneurysm is not immediately treated by the surgeon. A report of using the cephalic vein branch to treat this complication is uncommon. CASE PRESENTATION: Herein, we present a case of a 42-year-old man in whom an AVF with an aneurysm was successfully treated using the excess cephalic vein branch. This method is a simple and effective intervention for managing aneurysm-associated complications. Additionally, this approach helps maintain the benefits of autogenous access while conserving future dialysis sites. CONCLUSION: The surgery was effective and safe for this kind of complication with swollen hands and aneurysm. Using the excess cephalic vein branch could reconstruct the AVF.

Internal mammary vein diameter - Is the left side really smaller? A study of 105 bilateral free flap breast reconstruction patients.

INTRODUCTION: Autologous free flap breast reconstruction is currently considered as the gold standard in breast reconstruction as it provides a durable, natural result. The internal mammary vessels are the most commonly used recipient vessels in free flap breast reconstruction, and anecdotally we have often observed that the left internal mammary vein (IMV) appears smaller than the right IMV. The aim of this study is to compare the diameters of the right and left IMVs by recording the size of the venous coupler used on each side in a large series of bilateral free flap breast reconstructions. METHODS: We searched our free flap database for patients who had breast reconstruction between October 2018 and August 2021. Inclusion criteria for this study were bilateral breast reconstruction patients, where the internal mammary vessels were used. We used a paired t-test for statistical analysis of the data. RESULTS: A total of 105 patients who had bilateral breast reconstruction were included in this study. Their mean age was 48.4 years. The mean venous coupler size used on the right was 2.64 mm (SD 0.35), whilst the mean left IMV coupler size was 2.48 (SD 0.32). Using a paired t-test, the p value for the comparison of the right and left IMV size in the cohort was 0.00032, demonstrating a statistically significant difference. CONCLUSION: We have confirmed that the right IMV is larger in diameter than the left side, and demonstrated that this translates into a recordable practical difference in the coupler size used. Despite this, we experienced no venous congestion or flap failures in our left-sided flaps, indicating that the IMVs remain a safe choice of recipient vein.

Transposition of basilic vein for vascular access for haemodialysis: An experience of a tertiary care hospital.

Basilic vein transposition (BVT) is the preferred permanent haemodialysis access due to better patency and lower infection rates compared to synthetic grafts. The outcomes of BVT cases, performed at Shifa International Hospital, Islamabad, from March 2006 to June 2018, were ambispectively investigated. The primary patency of the fistula was assessed immediately after surgery, at 24 hours, at 7-14 days, at 6-8 weeks and then at 3-6 months. A total of 160 patients were included in the study, out of which 83 (51.87%) were males while 77 (48.12%) were females. Of the total 160 patients, 119 (74.4%) underwent one stage BVT, while 41 (25.6%) underwent two stage BVT. One hundred and thirty-five (84.4%) procedures were successful and survived while in 25 (15.6%) cases it failed. Mean basilic vein diameter was 2.712±0.772 mm. Overall, 10(6.3%) patients had bleeding, 15(9.4%) fistulae thrombosed, 6(3.8%) had steal syndrome and only 1 (0.6%) patient developed pseudo aneurysm. We conclude that BVT is a feasible technique with very good patency rate especially for those patients who have multiple forearm AVF surgeries.

Evaluation of Ethyl Violet as an Alternative Dye to Crystal Violet to Visualize the Vessel Wall during Vascular Anastomosis.

Crystal violet (CV) ink has been used as a skin marker worldwide. It has been reported to be useful for vessel wall visualization of microvascular anastomoses. Contrastingly, it has been found to be carcinogenic and inhibit migration and proliferation of venous cells. In some countries, its use in the medical field has been restricted. Therefore, it is necessary to consider alternatives to CV. In this present study, we compared the time required for the anastomosis of a 0.8-1 mm diameter vessel in the chicken wrist artery using CV and a CV-free dye (ethyl violet; EV). The surgeon, microscope, and anastomosis microsurgical tools were standardized for comparison. CV and EV were changed for each anastomosis. The same surgeon performed 30 anastomoses using each dye. No visually obvious differences were noted in the vascular transections with CV and EV. As per the results, no statistically significant difference was observed in the time required for anastomosis using CV and EV. EV conforming to California Proposition 65 may be an effective alternative to CV for vascular visualization of microvascular anastomoses. However, further studies on the effectiveness of the EV in clinical cases are needed.

Selection of deep or superficial recipient vein in lower extremity reconstruction using free flap: A systematic review and meta-analysis.

BACKGROUND: Free flap surgeries are useful procedures for lower-extremity reconstruction. Recipient vein selection for anastomosis is important to avoid venous congestion and thrombosis. Although deep or superficial venous system can be used as a recipient vein site, there is a lack of consensus on which system would be superior to avoid postoperative complications. This systematic review and meta-analysis aimed to assess the differences in outcomes between deep and superficial vein anastomosis for lower-extremity free flap reconstruction. METHODS: The PubMed, Scopus, Web of Science, and Cochrane Library medical databases were systematically searched from inception to April 2022, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A comparative meta-analysis was conducted on studies of deep and superficial venous system anastomosis outcomes, comprising vascular thrombosis, reoperation, complete flap necrosis, and any flap necrosis. The fixed-effects meta-analysis model was used when low heterogeneity (I2 < 50%) was present. RESULTS: Six studies with 789 flaps were included in the analysis and qualitative and quantitative syntheses. The rate of vascular thrombosis (8.2% vs. 15.1%; p = .005) was significantly lower for flaps involving deep vein anastomosis than for those involving superficial vein anastomosis. The rate of reoperation after deep vein anastomosis was lower than that after superficial vein anastomosis, with no statistically significant difference (9.0% vs. 14.7%; p = .06). There were no significant differences in the rates of complete (2.5% vs. 2.0%; p = .90) or any flap necrosis (7.0% vs. 9.8%; p = .20). CONCLUSION: Deep vein anastomosis might be recommended for avoiding vascular thrombosis.

Retrograde Free Venous Flaps for Extremity Reconstruction: A Roadmap.

Background and Objectives: Retrograde free venous flaps represent a separate entity among free venous flaps: their physiology is still unclear, but they provide an immediate visible refill after reconnection, with a similar behaviour to conventional flaps. Therefore, the dimensions and the indications of these flaps can be extended beyond what was previously believed, and they can be easily customized, including with respect to tendons and nerves. Nevertheless, they are still debated and regarded as unsafe. Materials and Methods: From 2012 to 2019, we performed 31 retrograde free venous flaps on 31 patients to reconstruct hands, digits, and in one case the heel. All the flaps were arterialized in a retrograde manner; the donor site was the forearm in 28 cases, the foot in 2 cases, and the calf in 1 case. We recorded the size, vein architecture, donor site, donor artery, donor morbidity, function for composite and non-composite flaps, immediate complications, late complications, survival rate, and the number of revisions. We recorded the hand function when appropriate. A total of 10 flaps were also intraoperatively studied with indocyanine green to monitor their hemodynamical behaviour. Results: All the patients were followed for an average of 8 months (6-15). The flap dimensions ranged from 6 cm2 to 136 cm2. All the flaps, except two that had complete necrosis, survived. Two flaps had partial necrosis. There was no correlation between necrosis and the size of the flap, with one case of necrosis and one of partial necrosis in the small flaps (<10 cm2). None of the cases with partial necrosis needed a new flap. Two flaps developed a late arterio-venous shunt that was ligated. Conclusions: The retrograde free venous flaps proved to be a useful tool for complex reconstructions of the hand and extremities. They can provide a large island of pliable skin and composite tissue with tendons and nerves, but surgeons must be aware of some caveats.

Utilizing a lower extremity vein graft for immediate lymphatic reconstruction.

Immediate lymphatic reconstruction (ILR) is targeted at preventing breast cancer related lymphedema (BCRL) by anastomosing disrupted arm lymphatic channels to axillary vein tributaries. Inadequate vein length and venous back-bleeding are two technical reasons that lead to ILR procedures being aborted intraoperatively. Recently, our team began routinely harvesting a lower extremity vein graft (LEVG) for all ILR procedures to reduce our abort rate. We describe the surgical approach of an LEVG and evaluate the effects on aborted case rates and intraoperative time. A retrospective review of our institutional lymphatic database was conducted. Two hundred and forty-seven breast cancer patients were taken to the operating room for attempted ILR in the past 5 years. Prior to the use of an LEVG (n = 205), our abort rate was 14%. Since routinely performing an LEVG with ILR (n = 42), we have not aborted a single case. Despite an LEVG requiring one additional anastomosis to connect the vein graft to the native axillary vein tributary, this technique has not changed the intraoperative time for ILR procedures. In this technical contribution, we describe our early experience performing immediate lymphatic reconstruction utilizing a lower extremity vein graft. Implementation of this technique appears to have promising effects on aborted case rates without affecting intraoperative time, and greatly facilitates the lymphovenous anastomosis.

The Superficial Vein-Only DIEP Flap.

BACKGROUND: The deep inferior epigastric artery perforator (DIEP) flap, often considered the standard in autologous breast reconstruction, is reliant on robust arterial inflow and venous outflow. Venous outflow issues remain a critical part in determining the success of the DIEP flap. Previously, the superficial inferior epigastric vein (SIEV) has been used to augment venous outflow, or as a salvage option when flow through the deep inferior epigastric vein is compromised or insufficient. The authors describe a variant of the DIEP flap, the superficial vein-only DIEP flap, using the deep inferior epigastric artery and the SIEV as a viable alternative when indicated. METHODS: The authors conducted a retrospective review of all patients undergoing autologous breast reconstruction performed by the senior author (B.C.) from July of 2015 to March of 2020 to identify DIEP flaps whose only source of venous outflow was the SIEV, excluding those performed as salvage maneuvers. RESULTS: The authors identified 30 patients (35 flaps) and describe their characteristics, flap characteristics, complications, and details of the flap harvest. Notably, the authors experienced complications in 26.7 percent of flaps, of which 62.5 percent were minor, with no flap loss. This was comparable to the complication rate observed in the standard DIEP flap population. CONCLUSIONS: The authors believe the superficial vein-only DIEP flap is an excellent option for the appropriate patient. It is an added tool to make abdominally based breast reconstruction more reliable and successful. The use of the SIEV in a superficial vein-only flap should be considered as part of any routine DIEP flap reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Percutaneous Arteriovenous Fistula Creation with Intended Brachial Vein Outflow and Secondary Brachial Vein Transposition Using the WavelinQ EndoAVF System.

PURPOSE: To assess percutaneous arteriovenous fistula (pAVF) creation with subsequent brachial vein transposition (BVT) using the WavelinQ endoAVF system. MATERIALS AND METHODS: A pre-existing database was retrospectively reviewed. Nine patients underwent attempted pAVF-BVT creation between December 2017 and November 2021. Study outcomes included technical success, time to maturation, patency rates, adverse events, and secondary interventions. Maturation was defined as a pAVF flow of ≥500 mL/min, outflow vein diameter ≥5 mm, and successful 2-needle cannulations in patients on active hemodialysis (HD). RESULTS: pAVF-BVT creation was technically successful in 8 of 9 patients (89%). Six of 8 created pAVFs remained patent and matured at 4 weeks, subsequently undergoing secondary BVT. Primary patency rates at 6, 12, and 24 months were 37.5%, 12.5%, and 12.5%, respectively. Secondary patency rates at 6, 12, and 24 months were 75%, 37.5%, and 37.5%, respectively. One patient had postprocedural access site bleeding, and 4 required secondary interventions to maintain patency. Two patients with failed pAVFs with BVT were successfully converted to surgical AVFs, probably facilitated by sufficient enlargement of superficial veins following pAVF creation. CONCLUSIONS: Off-label use of the WavelinQ system to create brachial vein outflow pAVF with BVT may be an alternative procedure for HD access creation in select patients with exhausted superficial veins.