Living donor kidney transplant following nephrectomy for renal artery stenosis with arterial reconstruction and viability assessment using ex vivo normothermic perfusion

Ex vivo normothermic perfusion (EVNP) is increasingly recognised as a viability tool to increase organ utilisation in deceased donor transplantation. We report the use of EVNP to assess graft perfusion quality following indication nephrectomy and back-bench arterial reconstruction in a case of renal artery stenosis, unamenable to endovascular treatment. Once explanted, it was not possible to effectively cold perfuse the graft through the main renal artery or collaterals. An arterial reconstruction was performed with patch angioplasty using the largest collateral creating a single common stem. EVNP was used to assess organ perfusion and, therefore, viability. Excellent global perfusion was evident alongside urine production, demonstrating that the arterial reconstruction was satisfactory. A patient with end-stage renal disease was consented with particular attention to the uncertainty of the underlying donor disease process and long-term outcome of the reconstruction. Primary function was achieved and recipient estimated glomerular filtration rate (eGFR) remains stable at 58 mL/min/1.73 m² at 6 months.

EP.WE.567Regional anaesthesia for infra-inguinal revascularisation in patients with symptomatic peripheral arterial disease

Introduction General anaesthesia is considered to be an aerosol generating procedure. The global Covid-19 pandemic has resulted in review of practice to reduce risk to both patients and health care workers. The outcome of regional anaesthesia (RA) for infra-inguinal arterial reconstruction in patients with symptomatic occlusive atherosclerotic has been explored and compared with patients managed with general anaesthesia (GA). Methods Patients undergoing infra-inguinal revascularisation between 2019-2020 were identified from a prospectively maintained administrative theatre dataset. Case-linkage was used to complete the dataset. Specific end points included to critical care admission and peri-operative mortality. Results There were 204 patients identified (46 RA and 158 GA). The mean age of patients in both groups was 67-years and procedures were commonly performed in male patients (although the male:female ratio was higher in the RA group 2.8:1 than in the GA group 1.4:1). More patients in the RA had intervention for chronic limb threatening ischaemia (80% versus 59%). The interventions performed were comparable in both groups. The mean length of procedure was less in the RA group (142-minutes versus 160-minutes). No patients in the RA required admission to critical care (10 patients managed with GA required admission to critical care). The 30-day mortality was comparable in the RA and GA groups (2.2% and 1.9% respectively). Conclusions Regional anaesthesia would appear to be feasible for patients undergoing infra-inguinal arterial reconstruction with a reduction in operating time and critical care admission without increased peri-operative risk.

The level of markers of apoptosis and cell proliferation in the area of restenosis after lower extremity arterial reconstruction

Aim. To assess the number of markers of apoptosis and cell proliferation, as well as their relationships in the area of restenosis of arterial reconstructions. Methods. The study included 14 patients with a diagnosis of arteriosclerosis obliterans of the lower extremities. Post-thrombotic occlusion of femoropopliteal bypass. All patients were males with stage III disease according to the Fontaine classification modified by A.V. Pokrovsky. The average age of the patients was 653.4 years. The mean disease duration was 92.5 months after the initial intervention. Intraoperative material distal anastomosis of femoropopliteal bypass was taken from patients during arterial reconstructions. As a control, we used arterial wall samples obtained at organ procurement from postmortem donors without arteriosclerosis obliterans of the lower extremities. The number of samples is 8. The site of their collection is the popliteal artery. After sampling, they were crushed, and a homogenate was prepared, followed by the determination of the amount of p53, PDGF BB, Bcl2, and Bax proteins using the enzyme immunoassay. Statistical analysis was performed using the Statistica 10.0 software. Group differences were assessed by using the MannWhitney test. Correlation coefficients were determined using the Spearman test. Data are presented as medians and interquartile ranges. Results. In tissue samples of restenosis, the amount of p53 protein was 0.07 units/mg and was significantly reduced compared with the control samples 0.14 units/mg (р=0,015). The amount of platelet-derived growth factor PDGF BB was 0.17 ng/mg (р=0.05), Bcl2 1.61 ng/mg (р=0.008), Bax 6.0 ng/mg (р=0.25) in the restenosis area and was increased in comparison with the control samples (0.04 ng/mg, 0.9 ng/mg, 4.4 ng/mg, respectively). A relationship between p53 and platelet-derived growth factor BB (r=0.724, p=0.002), platelet-derived growth factor BB and Bcl2 (r=0.672, p=0.003) was revealed in samples from restenosis tissue obtained during arterial reconstructions. Conclusion. The decreased apoptosis, expressed in a low level of p53 protein, with an increased Bax/Bcl-2 ratio is associated with an increase in the proliferative response of vascular wall cells in the area of restenosis of arterial reconstruction.

Post-traumatic arteriovenous fistulae of the extremities: a case series

Post-traumatic AVF can lead to congestive heart failure, and limb ischemia. The objective of the study is to determine presentations, interventions and outcomes (morbidity and mortality) of the patients treated with traumatic AVF at a university hospital between Jan 1995 to December 2018. Nine patients (M: F 8:1) with median age of 30 [IQR 24.5] years were included in the study. They presented as ‘missed injuries’ with median delay of 4 [IQR 55.25] months. Most had penetrating injuries and presented with painful limb swelling, pain and venous ulcer. Superficial femoral (33.3%) and popliteal (22.2%) vessels were the most involved vessels. Seven (77.7%) patients had surgery while two (22.2%) had endovascular interventions. Arterial reconstruction with interposition vein (44.4%) or with prosthetic (11.1%) grafts was done. There was no peri-operative morbidity or 30-day mortality. All patients had smooth recovery with 100% limb salvage rate. Continuous..

Outcomes after Arterial Reconstruction with Autogenous Vein Graft for Limb Salvage in Traumatized Extremity

Purpose: The patients with major vascular injuries in the traumatized extremity and underwent arterial reconstruction using autogenous vein grafts for limb salvage. This study aims to report the outcomes of arterial reconstruction with autogenous vein graft in patients.Methods: From February 2015 to April 2017, a study was retrospectively analyzed 13 patients with limb injuries caused by significant arterial damage and underwent arterial reconstruction using vascular autografts for limb salvage. Such as cause, Mangled Extremity Severity Scores (MESS), ischemic time, length of the grafted vein, reconstructed arterial status, and survival status were analyzed. Results: Among the patients analyzed, nine patients’ injuries were caused by traffic accidents and three industrial accidents, one fall down. Mean MESS was 6.2 (range, 5–8) and mean ischemic time was 12.3 hours (range, 5–25 hours). As arterial reconstruction, seven patients underwent posterior tibial artery reconstruction, three underwent popliteal artery reconstruction, two underwent anterior tibial artery reconstruction, and one underwent radial artery reconstruction; the greater saphenous vein was grafted in 12 reconstruction cases. Mean length of the grafted vein was 4.9 cm (range, 3–10 cm). All patients have salvaged injured limbs.Conclusion: Artery reconstruction using autogenous vein graft is an efficient treatment method when vascular damage cannot be directly repaired during limb salvage.

Pre-operative/Neoadjuvant Therapy and Vascular Debranching Followed by Resection for Locally Advanced Pancreatic Cancer (PREVADER): Clinical Feasibility Trial

Introduction: Pancreatic cancer continues to have a poor outcome. Many patients are diagnosed with advanced disease, and in a considerable proportion, abutment or invasion of visceral arteries is present. Moreover, some patients have anatomical variations or stenosis of major visceral arteries requiring arterial reconstruction upon pancreatic cancer resection to avoid organ ischemia. Simultaneous arterial reconstruction during resection is associated with relevant morbidity and mortality. This trial evaluates the approach of visceral debranching, that is, arterial reconstruction, prior to neoadjuvant chemotherapy and tumor resection in patients with locally advanced, unresectable pancreatic cancer.Methods and Analysis: The trial includes patients with locally advanced, non-metastatic pancreatic cancer with arterial abutment or invasion (deemed primarily unresectable), variations in vascular anatomy, or stenosis of visceral arteries. The participants undergo visceral debranching, followed by current standard neoadjuvant chemotherapy (mFOLFIRINOX, gemcitabine–nab-paclitaxel, or other) and potential subsequent tumor resection. The primary outcome is feasibility, measured as the proportion of patients who start neoadjuvant therapy within 6 weeks of visceral debranching. The trial has an exact single-stage design. The proportion below which the treatment is considered ineffective is set at 0.7 (H0). The proportion above which the treatment warrants further exploration in a phase III trial is set at 0.9 (H1). With a power (1-beta) of 0.8 and a type 1 mistake (alpha) of 0.05, the required sample size is 28 patients. Feasibility of the approach will be assumed if 24 of the enrolled 28 patients proceed to neoadjuvant chemotherapy within 6 weeks from visceral debranching.Discussion: This trial evaluates a new treatment sequence, that is, visceral debranching followed by chemotherapy and resection, for pancreatic cancer with invasion or abutment of visceral arteries. The primary objective of the trial is to evaluate feasibility. Trial results will allow for estimating treatment effects and calculating the sample size of a randomized controlled trial, in which the approach will be tested if the feasibility endpoint is met.Clinical Trial Registration:clinicaltrials.gov, identifier: NCT04136769.