Vein-first versus artery-first ligation procedure for lung cancer surgery: An updated review

Background The optimal sequence of pulmonary vessel interruption during lung cancer resection remains controversial. This review aimed to elucidate the association of vein-first versus artery-first ligation and survival of the patients. Methods We searched PubMed, Web of Science, Scopus, Embase, Cochrane Library and Google Scholar from their inception to September 2021 for published articles that compared vein-first (the pulmonary vein was interrupted first) and artery-first procedure (the pulmonary artery was ligated first) during lung cancer surgery. Results Finally, a total of 13 full articles were obtained. First, 7 studies with survival information were included for meta-analyses. As compared with the artery-first ligation, vein-first approach did not decrease the risk of local recurrence (risk ratio [RR] 0.92 in favour of vein-first; 95% confidence interval [CI] 0.61–1.39, p = 0.68) or distant metastasis (RR 0.92; 95% CI 0.30–2.85, p = 0.89); but it was associated with better disease-free survival (RR 0.52; 95% CI 0.37–0.73, p < 0.01) as well as 5-year overall survival (RR 0.60; 95% CI 0.41–0.86, p < 0.01). In addition, the operative time, intraoperative blood loss, total complications, and length of postoperative stay were mainly comparable between the two groups. Second, 7 studies provided the data of tumor cells indicated by different biomarkers and detection methods; and 3 of these reports showed that vein-first ligation decreased the extent of intraoperative tumor dissemination. However, a quantitative meta-analysis was not possible due to the significant heterogeneity. Conclusion Vein-first ligation in lung cancer surgery may be associated with improved survival of the patients, which might be ascribed to potentially lower risk of tumor cell dissemination. Well-designed, large-scale trials are warranted to clarify these occasional findings.

Effects of Vessel Interruption Sequence During Lobectomy for Non-small Cell Lung Cancer: A Systematic Review and Meta-Analysis

Background: For lobectomy in non-small cell lung cancer (NSCLC), whether interrupting the pulmonary vein first (Vein-first) achieves better perioperative and survival outcomes than interrupting the pulmonary artery first (Artery-first) remains controversial. We conducted this meta-analysis to compare outcomes between the two groups to facilitate better surgical decision-making.Methods: Web of Science, EMBASE, Cochrane Library, Ovid MEDLINE, PubMed, ScienceDirect, and Scopus were searched for eligible studies comparing Vein-first and Artery-first procedures. The primary endpoints were survival indicators [overall survival (OS), disease-free survival (DFS), and lung cancer-specific survival (LCSS)]. Secondary endpoints included intraoperative indicators, hospitalization, and follow-up indicators.Results: After screening 2,505 studies, 8 studies involving 1,714 patients (Vein-First group: 881 patients; Artery-first group: 833 patients) were included. The vein-first group achieved better OS [HR (hazard ratio): 1.46, 95% confidence interval (CI): 1.12–1.91, p = 0.005], DFS (HR: 1.60, 95% CI: 1.23–2.08, p &lt; 0.001), and LCSS (HR: 1.64, 95% CI: 1.16–2.31, p = 0.005). The survival rates of OS at 2–5 years, DFS at 1–5 years, and LCSS at 3–5 years were also higher in the Vein-First group. Subgroup analyses suggested that the advantages of survival in the Vein-First group were primarily embodied in the subgroups of squamous cell carcinoma (SCC) and earlier pathological TNM stage (I–II). Operative time, intraoperative blood loss, total complications, and total recurrences were comparable between the two groups.Conclusions: The Vein-first sequence is the suitable choice of vessel interruption sequence during lobectomy for NSCLC with better survival and similar perioperative outcomes, especially for stage I–II SCC.

Safety and Outcomes of Thrombectomy in Ischemic Stroke With vs Without Intravenous Thrombolysis

Objective:To test the hypothesis that intravenous thrombolysis (IVT) treatment prior to endovascular thrombectomy (EVT) is associated with better outcomes in patients with anterior circulation large artery occlusion (LAO) stroke, we examined a large real-world database, the SITS-International Stroke Thrombectomy Register (SITS-ISTR).Methods:We identified centers recording ≥10 consecutive patients in the SITS-ISTR, with at least 70% available modified Rankin Scale (mRS) scores at 3 months during 2014-19. We defined LAO as intracranial internal carotid artery, first and second segment of middle cerebral artery and first segment of anterior cerebral artery. Main outcomes were functional independence (mRS 0-2) and death at 3 months and symptomatic intracranial hemorrhage (SICH) per modified SITS-MOST. We performed propensity score matched (PSM) and multivariable logistic regression analyses.Results:Of 6350 patients from 42 centers, 3944 (62.1%) received IVT. IVT+EVT treated patients had less frequent atrial fibrillation, ongoing anticoagulation, previous stroke, heart failure and pre-stroke disability. PSM analysis showed that IVT+EVT patients had a higher rate of functional independence than EVT alone patients (46.4% vs. 40.3%, p<0.001) and a lower rate of death at 3 months (20.3% vs. 23.3%, p=0.035). SICH rates (3.5% vs. 3.0%, p= 0.42) were similar in both groups. Multivariate adjustment yielded results consistent with PSM.Interpretation:Pretreatment with IVT was associated with favorable outcomes in EVT-treated LAO stroke in the SITS Thrombectomy Registry. These findings, while indicative of international routine clinical practice, are limited by observational design, unmeasured confounding and possible residual confounding by indication.Classification of Evidence:This study provides Class II evidence that IVT prior to EVT increases the probability of functional independence at 3 months compared to EVT alone.

The Ablation of Thyroid Nodule’s Afferent Arteries Before Radiofrequency Ablation: Preliminary Data

Induced radiofrequency thermal ablation is the cytoreductive treatment of symptomatic benign thyroid nodules, metastatic and recurrent thyroid tumors and papillary thyroid microcarcinomas. It is a safe and effective alternative to surgery and it allows to obtain satisfactory results in terms of volumetric reduction of the nodule with significant improvement in the quality of life. The trans-isthmic approach and the moving shot technique are the two basic techniques; however, an advanced technique, artery-first feeding radiofrequency ablation, has been developed and validated. We have prospectively included 29 consecutive patients who have undergone radiofrequency ablation (Group A) or artery- first vRFA (Group B). All included patients had a diagnosis of benign nodular goiter and they underwent a single session of radiofrequency ablation. All patients followed a follow-up program at 1 month, 3 months, and 6 months. Continuous variables (age, TSH value, basal volume of nodule, used Joule, time in second of the procedure, nodules’ volume at 1-, 3-, and 6- months of follow-up and percentage of volume reduction at 1-, 3-, and 6- months of follow-up) were described as mean, standard deviation and range, while categorical variables (gender, nodule structure and nodule vascularization) were described as number of cases and percentage. Independent samples t-test were performed to compare the continuous variables. A Test of Proportions was applied to the categorical variables. The Fisher’s exact test was used to analyze the gender. Statistical significance was considered in case of p-value &lt;0.05. Solid structure and spongiform structure showed statistic differences with p-values of 0.022 and 0.023 respectively between two groups. The percentage of reduction at 1 month did not show a significant difference between two groups; instead, the percentage of volume reduction was decreased mostly in the Group B at 3 months and 6 months of follow-up with a p-value of 0.003 and 0.013, respectively. The Joules/energy used showed a statistically significant difference (p-value=0.05), more energy must be used in vascular radiofrequency ablation. These data allow us to hypothesize that vRFA may improve the effectiveness of the procedure, allowing for a reduction in volume more quickly. They were preliminary but promising results, clearly a larger series of cases and prolonged follow-up are needed to clarify and confirm our observations.

Vein or artery-first resection in right middle lobe segmentectomy: which preserves more lung?

We report the thoracoscopic RS5 segmentectomy with VVBA (V, vein; V, ventilation; B, bronchus; A, artery) method and confirmed that the segmental plane visualized by vein-first resection is slightly narrower than the traditional artery-first resection.

Approaches and Postoperative Complications of Artery-First Pancreaticoduodenectomy in a Tertiary Care Hospital in Nepal: A Descriptive Cross-sectional Study

Introduction: Superior mesenteric artery first pancreaticoduodenectomy is being increasingly used for pancreatic head and peri-ampullary tumors. The aim of our study was to determine the frequency of various approaches of superior mesenteric artery pancreaticoduodenectomy along with its postoperative complications in a tertiary care center. Methods: This is a descriptive cross-sectional study of patients undergoing superior mesenteric artery first pancreaticoduodenectomy with different approaches conducted at Kathmandu Medical College Teaching Hospital, Sinamangal, Kathmandu, Nepal, from May 2018 to April 2020. Ethical approval was taken from the Institutional Review Committee (reference no: 310520193). The whole sampling method was adopted. Thirty-four patients undergoing a superior mesenteric artery first pancreaticoduodenectomy at our center with different approaches were included in the study. The data analysis was done in the Statistical Package for the Social Sciences version 20. Results: For 34 patients chosen for the study, the male: female ratio was 1.6:1, with a mean age of 53.7 years. The medial uncinate approach was done in the majority of the cases, 26 (76.4%), whereas the inferior infracolic (mesenteric) approach was done in 1 (2.9%) case. Regarding postoperative complications, Clavien Dindo grade 3 and grade 4 were present in 11 (32.3%) patients, pancreatic fistula (Grade B and C) was observed in 6 (17.6%) patients, and mortality occurred in 2 (5.8%). The mean hospital stay was 16±9 days. Conclusions: Superior mesenteric artery first pancreaticoduodenectomy with a different approach can be performed with acceptable morbidity and mortality. Early determination of resectibility is achieved in selected cases.