Use of a Novel Bicarbonate-Based Impella 5.5 Purge Solution in a Coagulopathic Patient

The Impella 5.5 with SmartAssist (Abiomed; Danvers, MA) is a life-saving treatment option in acute heart failure which utilizes a continuous heparin purge solution to prevent thrombosis. In patients with contraindications to heparin, alternative anticoagulation strategies are required. We describe the stepwise management of anticoagulation in a coagulopathic patient with persistent cardiogenic shock following a coronary artery bypass procedure who underwent Impella 5.5 placement. A direct thrombin inhibitor-based purge solution was utilized while evaluating for heparin-induced thrombocytopenia. Use of a novel bicarbonate-based purge solution (BBPS) was successfully used due to severe coagulopathy. There were no episodes of pump thrombosis or episodes of severe bleeding on the BBPS and systemic effects of alkalosis and hypernatremia were minimal.

Right anterior minithoracotomy with total central cannulation

A right anterior minithoracotomy is gaining wider acceptance among the members of the surgical community for the treatment of isolated aortic valve replacement. Usually, the cardiopulmonary bypass circuit is implanted either totally peripherally or with 1 cannula in a central position and the other in a peripheral one. This procedure has its drawbacks because it adds potential peripheral morbidity during or after the operation. At our center, during the last year, we have developed some tips and tricks in order to establish in most of the patients a total central cardiopulmonary bypass procedure. We explain this technique in our video tutorial. We think that this approach may help other surgical teams to embrace a right anterior minithoracotomy because it is similar to what we do routinely by sternotomy.

Direct versus indirect bypass procedure for the treatment of ischemic moyamoya disease: results of an individualized selection strategy

OBJECTIVEThe only effective treatment for ischemic moyamoya disease (iMMD) is cerebral revascularization by an extracranial to intracranial bypass. The preferred revascularization method remains controversial: direct versus indirect bypass. The purpose of this study was to test the hypothesis that method choice should be personalized based on angiographic, hemodynamic, and clinical characteristics to balance the risk of perioperative major stroke against treatment efficacy.METHODSPatients with iMMD were identified retrospectively from a prospectively maintained database. Those with mild to moderate internal carotid artery or M1 segment stenosis, preserved cerebrovascular reserve, intraoperative M4 segment anterograde flow ≥ 8 ml/min, or the absence of frequent and severe transient ischemic attacks (TIAs) or stroke had been assigned to indirect bypass. The criteria for direct bypass were severe ICA or M1 segment stenosis or occlusion, impaired cerebrovascular reserve or steal phenomenon, intraoperative M4 segment retrograde flow or anterograde flow < 8 ml/min, and the presence of frequent and severe TIAs or clinical strokes. The primary study endpoint was MRI-confirmed symptomatic stroke ≤ 7 days postoperatively resulting in a decline in the modified Rankin Scale (mRS) score from preoperatively to 6 months postoperatively. As a secondary endpoint, the authors assessed 6-month postoperative DSA-demonstrated revascularization, which was classified as < 1/3, 1/3–2/3, or > 2/3 of the middle cerebral artery territory.RESULTSOne hundred thirty-eight patients with iMMD affecting 195 hemispheres revascularized in the period from March 2016 to June 2018 were included in this analysis. One hundred thirty-three hemispheres were revascularized with direct bypass and 62 with indirect bypass. The perioperative stroke rate was 4.7% and 6.8% in the direct and indirect groups, respectively (p = 0.36). Degree of revascularization was higher in the direct bypass group (p = 0.03). The proportion of patients improving to an mRS score 0–1 (from preoperatively to 6 months postoperatively) tended to be higher in the direct bypass group, although the difference between the two bypass groups was not statistically significant (p = 0.27).CONCLUSIONSThe selective use of an indirect bypass procedure for iMMD did not decrease the perioperative stroke rate. Direct bypass provided a significantly higher degree of revascularization. The authors conclude that direct bypass is the treatment of choice for iMMD.

Left A2 Fusiform Aneurysm: 2-Dimensional Operative Video

Anterior cerebral artery aneurysms within the A2 segment that are fusiform or giant A2 aneurysms with a wide neck often are not candidates for endovascular treatment and require surgical intervention. These lesions necessitate a bypass procedure to preserve distal flow along the anterior cerebral artery. This patient demonstrated a left-sided unruptured A2 fusiform aneurysm that necessitated a bypass procedure for management. The patient was positioned with the head rotated laterally to permit orientation of the interhemispheric fissure within the horizontal plane and achieve gravity retraction of the dependent hemisphere. The bilateral pericallosal branches were exposed and liberated from arachnoid adhesions to permit mobilization necessary for the side-to-side anastomosis. While the anastomosis was performed, the continuous suture loops were left loose to permit complete visualization of the inner and outer walls prior to the final tightening and tying of the anastomotic suture. Following the completion of the anastomosis, the temporary clips were removed. A permanent clip was placed on the distal A2 to prevent outflow from the parent artery and thereby allow for aneurysm thrombosis. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

COMPARISON OF CONDUIT PATENCY AND ROLE OF ANTICOAGULANTS IN LONGITIVTIY OF PROSTHETIC GRAFT VERSUS AUTOLOGOUS SAPHENOUS VEIN FOR BELOW KNEE BYPASS GRAFTING IN CRITICAL LIMB ISCHEMIA

BACKGROUND: As established fact the autogenous vein is the conduit of choice in below-knee arterial bypasses . However, with availability of newer prosthetic grafts and usage of anti-platelets and anticoagulants , the results of these prosthesis's are also improving. so much so that in case of non availability of good GSV or malnourished patients where wound healing could be a concern prosthetic grafts can be used reasonably well. We also compared the outcomes of below-knee prosthetic versus autologous vein bypass grafts with different anti-platelets and anti-thrombotic medicines combinations to nd out whether the prosthesis performance improves with anticoagulants usage and whether the addition of anticoagulants to anti-platelets is causing more bleeding complications in these patients so much that they are to be used with caution. METHODS: For this study, we utilised treatment data of Department of CardioVascular and Thoracic Surgery ,Pt. J.N.M. Medical College Raipur. we studied 70 patients, Single surgeon experience. We included patients who underwent open below knee bypass procedure for critical limb ischemia (claudication/ rest pain/ non healing ulcers/ gangrenous changes) between January 1, 2018 and December 31, 2019. Our analysis was limited to patients whose graft origins were the ipsilateral iliac or femoral arteries and whose targets were the below-knee popliteal or tibial arteries. We analysed the results by evaluating the Graft Patency at 1 year, major amputation at 1 year, bleeding complications, association of bleeding complications to the combination of anti-platelets + anticoagulation. we also evaluated the patency at 1 year in relation to the distal anastomotic sites ( popliteal or infra popliteal ) and amputation in relation to the distal targets for bypass to understand that the disease load has any signicance in the patency and limb salvage in patients of lower limb ischemia. RESULTS :Atotal of 70 patients who underwent open below knee bypass procedure for critical limb ischemia were analysed; 35 patients (50%) received GSV and 35 patients (50%) received a prosthetic conduit. There was no signicant difference in primary patency due to Gender (Male 84.3%, Female 15.7%), Diabetes Mellitus (GSV 20%, Prosthetic 14.3%), Hypertension (GSV 31.4%, Prosthetic 45.7%) & Tobacco addition (GSV 100%, Prosthetic 94.3%). Baseline characteristics were similar among groups with the popliteal artery (54.3%) and infra popliteal arteries. i.e. tibioperoneal trunk (27.1%), Anterior Tibial (4.3%) and posterior tibial (14.3%). We found no signicant difference in primary graft patency (77% vs 71%, P= ) or major amputation rates (8.5% vs 17%, P= ) between GSVand Prosthetic conduit. The prosthetic graft patency was more when the anti platelets were combined with anticoagulants. Saphenous vein graft patients did well even with anti platelets single or combination. Bleeding complications were more common in the prosthetic group with anti platelets with anticoagulants. CONCLUSIONS:Although limited in size, our study demonstrates that, with appropriate patient selection and anti-thrombotic therapy, 1-year outcomes for below-knee prosthetic bypass graft can be comparable to those for greater saphenous vein conduit.Though the study does not challenge the superiority of vein graft for below knee bypass grafting , but in certain cases where needed prosthetic graft are denitely comparable in performance.