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We report a simplified Zone 2 arch repair using a trifurcated graft for acute type A aortic dissection. The right axillary artery is cannulated. After completion of proximal aortic repair using a one-branched graft, a trifurcated graft is anastomosed to the ascending graft just above the proximal suture line or coronary buttons in case of Bentall procedure. Distal aortic anastomosis is performed at the Zone 2 level under unilateral antegrade cerebral perfusion. Full cardiopulmonary bypass flow is resumed via the right axillary and ascending graft using both Y-shaped arterial limbs. The left common carotid and innominate artery are sequentially anastomosed.

Introduction Visceral artery injuries are rare but lethal entities that pose significant management challenges in a patient who presents with blunt trauma. There is a paucity of specific guidelines both in the trauma and vascular literature regarding the management of blunt intra-abdominal vascular injuries. The midterm outcomes of two cases of blunt traumatic visceral artery injuries managed successfully with endovascular interventions are presented. Report An 18 year old male victim of a motor vehicle accident was found to have infrarenal aortic, coeliac artery (CA), and superior mesenteric artery (SMA) injuries. The second patient was a 15 year old male who presented with traumatic occlusion of the CA after an all terrain vehicle collision. Both patients had other associated abdominal and bony injuries. All vascular injuries were addressed endovascularly, which was followed by repair of other associated injuries. In the first case, a self expanding non-covered nitinol stent was used in the injured but tortuous CA; for repair of the SMA, a covered balloon expandable stent was used. In the second patient, a balloon expandable non-covered stent was used to repair the CA occlusion. In both cases, the 12 month post-operative follow up showed that all stents were patent and the patients were asymptomatic. Discussion Endovascular repair of the mesenteric arteries following traumatic injury can be achieved safely, with good midterm outcomes. More data are needed to define the indications for and long term safety and patency of stents used in traumatic visceral artery injuries., Highlights • Blunt visceral artery trauma has devastating consequences, requiring prompt diagnosis and management. • Endovascular revascularisation of coeliac and superior mesenteric artery injuries is possible, with good peri-operative and midterm outcomes. • Further research is needed to understand the long term safety and efficacy of endovascular management of visceral artery injuries.

Beta-blockers (BBs) are first-line anti-impulse therapy for patients presenting with acute type B aortic dissection (TBAD). However, little is understood about their effects after aortic repair. The aim of the present study was to evaluate the role of postoperative BB use on the outcomes of thoracic endovascular aortic repair (TEVAR) in TBAD.The Vascular Quality Initiative database was queried for all patients who had undergone TEVAR for TBAD from 2012 to 2020. Aortic-related reintervention, all-cause mortality, and the effects of TEVAR on false lumen thrombosis of the treated aortic segment were assessed and compared between patients treated with and without BBs postoperatively. Cox proportional hazards models were used to estimate the effect of BB therapy on the outcomes.A total of 1114 patients who had undergone TEVAR for TBAD with a mean follow-up of 18 ± 12 months were identified. The mean age was 61.1 ± 11.9 years, and 791 (71%) were men. Of the 1114 patients, 935 (84%) continued BB therapy at discharge and follow-up. The patients taking BBs were more likely to have had an entry tear originating in zones 1 to 2 (22% vs 13%; P = .022). The prevalence of acute, elective, and symptomatic aortic dissection, prevalence of concurrent aneurysms, number of endografts used, distribution of proximal and distal zones of dissection, and operative times were comparable between the two cohorts. At 18 months, significantly more complete false lumen thrombosis (58% vs 47%; log-rank P = .018) was observed for patients taking BBs, and the rates of aortic-related reinterventions (13% vs 9%; log-rank P = .396) and mortality (0.2% vs 0.7%; log-rank P = .401) were similar for patients taking and not taking BBs, respectively. Even after adjusting for clinical and anatomic factors, postoperative BB use was associated with increased complete false lumen thrombosis (hazard ratio, 1.56; 95% confidence interval, 1.10-2.21; P = .012) but did not affect mortality or aortic-related reintervention. A secondary analysis of BB use for those with acute vs chronic TBAD showed a higher rate of complete false lumen thrombosis for patients with chronic TBAD and taking BBs (59% vs 38%; log-rank P = .038). In contrast, no difference was found in the rate of complete false lumen thrombosis for those with acute TBAD between the two cohorts (58% vs 51%; log-rank P = .158). When analyzed separately, postoperative angiotensin-converting enzyme inhibitor use did not affect the rates of complete false lumen thrombosis, mortality, and aortic-related reintervention.BB use was associated with promotion of complete false lumen thrombosis for patients who had undergone TEVAR for TBAD. In addition to its role in the acute setting, anti-impulse control with BBs appears to confer favorable aortic remodeling and might improve patient outcomes after TEVAR, especially for those with chronic TBAD.

Introduction: Inflammatory bowel disease (IBD) is a chronic multisystem inflammatory condition with associated endothelial dysfunction and dysregulated coagulation. Although deep venous thrombosis (DVT) in IBD has been well described, arterial thrombosis and thromboembolism are less commonly appreciated. Methods: A 63-year-old male with a known history of Crohn disease presented with acute-onset right arm pain. His past vascular history was significant for left lower extremity DVT with an existing inferior vena cava filter and acute ischemia of the right lower extremity requiring a below-knee amputation a year ago. Imaging revealed acute brachial, ulnar, and radial artery thrombosis. Results: Patient underwent an open right brachial, radial, and ulnar thrombectomy to restore vascular flow. He required multiple exploration and thrombectomy for reocclusion of the vessels in the early postoperative period. He later developed a rapidly deteriorating clinical status, flank ecchymosis and swelling concerning for soft tissue ischemia, and compartment syndrome heralding an eventual hemodynamic collapse. On exploration, he was found to have chronic fibrosis of his left femoral vein and femoral artery occlusion. Clinically, the patient deteriorated rapidly, which resulted in his demise. Conclusion: The inflammatory reaction in IBD leads to arterial stiffening and hypercoagulability, which should theoretically increase the risk for vascular disease. Although the link between IBD and DVT is well established, arterial thrombosis and thromboembolism remain widely debated, with some implications for therapeutic intervention. The link between vascular thrombosis and IBD must be examined further, as the treatment and prevention of vascular complications in IBD depends on our understanding of this relationship.

Background Clostridium septicum aortitis is a lethal infection. C. septicum has a strong association with an underlying malignancy, most commonly in the colon. Aim Early identification methods and management strategies of C. Septicum infection. Materials and methods We present a 64-year-old man with aortic aneurysm and C. septicum bacteremia with unknown malignancy who passed away on the fourth day of hospitalization despite emergent endovascular intervention. Computed tomography showed periaortic gas which is the hallmark of infection. Discussion This case report highlights the need of prompt surgical treatment and its different modalities along with the early use of appropriate antibiotics due to the rapid spread of infection associated with high fatality. The authors also discuss the association of C. septicum aortitis with underlying occult malignancies. Conclusion Delay in identification and treatment of C. Septicum is associated with very high mortality rates.

The use of telemedicine for mentoring and proctoring is long-standing, but only in recent years has it been applied to the many specialties in surgery. Despite being relatively new, the concept of telepresence and telesurgery and the new technological advances in robotic surgery have made possible telementoring and teleproctoring in many disciplines including such as e-ICU consultations and advise on how to manage a critically ill patient. This form of telementoring and teleproctoring is probably best known clinically relevant, yet it has been accepted as routine care. Other forms of telementoring and teleproctoring include telemedicine and telepresence applications for trauma, emergency management. In this chapter we will address telementoring, and to a lesser degree teleproctoring in just about all surgical disciplines with exception of gynecology and orthopedics.

Evidence-based medicine has demonstrated that the geriatric population is at risk for poor surgical outcomes due to the prevalence of chronic diseases such as hypertension, hyperlipidemia, diabetes, coronary artery disease, and chronic lung and kidney disease. These long-standing chronic medical conditions, together with years of exposure to environmental stressors, poor diet, nicotine, alcohol, polypharmacy etc., are strong risk factors for developing vascular pathologies requiring medical and surgical intervention. The incidence of arterial diseases increases with age. Vascular surgery as a branch of surgery deals with treating and attending to this unique age group of the population. It is important for the treating physician to understand the concepts of physiological changes in the vasculature in the elderly, the different disease processes that arise as a result of them, and the various modalities available for their management. The decision to perform a vascular procedure in the elderly does not depend on knowing merely what surgeries to perform. Understanding the patient’s social background, anticipated quality of life after intervention, and presence or absence of family support forms the other half of the toolkit required to provide not only the best available treatment for the disease but the best-suited management for that patient. This patient-centered approach with the patient participating in the overall management plan is the new paradigm. This chapter acknowledges the scope of this unique issue and analyzes various vascular diseases in the elderly with special focus on the current trends in diagnosis and treatment.

Objective To evaluate clinical outcomes from a postmarket registry of the Zenith Spiral-Z abdominal aortic aneurysm iliac leg graft with a continuous, spiral nitinol stent that was designed for improved conformability, kink, and migration resistance. Methods This prospective, multicenter registry was designed to evaluate physician-reported outcomes of the Spiral-Z leg graft in up to 600 patients who underwent endovascular repair of abdominal aortic or aortoiliac aneurysms at up to 30 investigative sites in the United States and Canada. Study outcomes were focused on iliac limb occlusion, limb-related reintervention, limb-related endoleak, component separation, and device integrity. Short-term data were collected during an interval of 1 to 6 months, with longer term data collected at 12 months. Results Between March 2012 and March 2015, 599 patients (mean age 74 ± 8 years; 87% male; 26% with aortoiliac aneurysm) were treated, with Spiral-Z iliac leg grafts placed in 564 left iliac arteries and 559 right iliac arteries. The mean iliac inner diameters (both left and right) were 9 ± 3 mm; moderate/severe occlusive disease, calcification, and vessel tortuosity were present in 14%, 25%, and 36% and 15%, 25%, and 34% of the left and right iliac arteries, respectively. Iliac artery adjunctive procedures (iliac artery angioplasty and/or stent placement) were performed intraoperatively in 112 patients (19%; bilateral in 52 patients). Mortality within 30 days was 1.7% (10/599); cumulative mortality at 1 year was 6.2% (37/599). There were no aortic ruptures and only one open conversion (0.2%). Limb occlusions occurred in 11 of 599 patients (2%; 3 within 30 days and 8 after 30 days, all unilateral, none had received procedural iliac artery adjuncts at implantation); of these, 7 patients underwent reinterventions. Other limb-related reinterventions were performed on eight patients for nonocclusive kink, compression, or thrombus (six within 30 days and three after 30 days). In total, 13 patients (2%) underwent 15 limb-related reinterventions (7 for occlusions and 8 for nonocclusive causes). In one patient, a distal type I endoleak and device migration (>10 mm) involving a right iliac leg was noted at the 12-month follow-up visit. No other limb-related endoleak, migration, component separation, or stent fracture was reported during a mean follow-up of 11 ± 6 months. Conclusions The Spiral-Z leg graft demonstrated excellent patency and required infrequent limb-related reinterventions in routine clinical care in a postmarket registry.

Severe convective phenomena cause significant loss in the economy and, primarily, casualties. Therefore, it is essential to forecast such extreme events to avoid or minimize the negative consequences. Wind shear provides an updraft-downdraft separation in the convective cell, which extends the cell lifetime. Wind shears between a few different air layers have been examined in all damaging convective cases in Poland, taken from the European Severe Weather Database between 2011 and 2015, in order to find their values and patterns according to the intensity of this phenomenon. Each severe weather report was assigned wind shear values from the nearest sounding station, and subsequently the presented summary was made. It was found that wind shear values differ between the given phenomena and their intensity. This regularity is particularly visible in shears containing 0 km wind. The highest shears occur within wind reports. Lower values are associated with hail reports. An important difference between weak and F1+ tornadoes was found in most of the wind shears. Severe phenomena probability within 0–6 km and 0–1 km shears show different patterns according to the phenomena and their intensity. This finding has its application in severe weather forecasting.

Given the deleterious effects of concomitant peripheral arterial disease (PAD) and severe renal disease, a role for aggressive screening and management of PAD in renal failure patients has been suggested. However, limited data exist detailing the impact of PAD on kidney waitlist survival and the potential benefit of transplantation in PAD. Multivariable COX regression and Kaplan-Meier survival models were fit using UNOS data to assess kidney waitlist and post-transplant five-yr survival. Compared to PAD-Dial- (no PAD or dialysis) waitlist survival, PAD+Dial- was associated with a 36%, PAD-Dial+ a 95%, and PAD+Dial+ a 190% increased risk of death. A significant survival benefit of kidney transplantation was identified in the PAD population (p < 0.001, HR = 0.440 comparing post-transplant to waitlist survival). Time to survival benefit (equal mortality between waitlist and post-transplant population) of kidney transplantation in PAD+ was realized 2.5 times sooner in pre-emptive transplantation than transplant after dialysis (154 d vs. 381 d), per unadjusted Kaplan-Meier analysis. To our knowledge, this is the first study to demonstrate a survival benefit of kidney transplantation in the setting of PAD. Pre-emptive transplantation with emphasis on living donation prior to dialysis should be advocated to improve outcomes in this high risk patient population.

Both antigen-dependent and -independent factors influence long-term organ allograft function and survival. Brain death (BD), a significant antigen-independent, donor-related injury upregulates a variety of inflammatory mediators in peripheral organs. One of the earliest responses to such an insult is the expression of selectins by endothelial cells of the transplanted tissues; these in turn trigger a cascade of nonspecific events, that enhance host alloresponses and which may be worsened by toxic effects of long-term immunosuppression. Using a rat model in which donor BD accentuates subsequent renal allograft injury, we have tested the effects of therapy with recombinant P-selectin glycoprotein ligand (rPSGL-Ig) alone, or in combination with sirolimus (SRL) and cyclosporin A. We found that in contrast to the effects of standard doses of SRL or cyclosporine, rPSGL-Ig decreased inflammation in the early posttransplant period such that lower doses of maintenance immunosuppression were sufficient to maintain long-term graft function.

Organ allografts, particularly from less than optimal donors, may not be biologically inert at the time of transplantation but may trigger or amplify subsequent host responses against the foreign tissues. These potentially activated organs may provoke a continuum between the inflammatory changes evoked in the recipient by initial nonspecific, antigen-independent insults and the later onset of antigen-dependent, immunologic alloresponsiveness. Older donors, hypertension and other donor factors, the peripheral events surrounding brain death, the use of non-heart-beating donors, and ischemia-reperfusion injury may all contribute to initial graft injuries. These in turn may provoke the eventual onset of progressive chronic graft dysfunction. The effects of these insults, with special reference to cardiac transplants, are reviewed.

BACKGROUND The lack of adequate numbers of kidneys for transplantation has stimulated interest in the use of organs from non-heart-beating donors (NHBDs). The short- and long-term effects of this risk factor on kidney isografts and allografts were examined with a rat model. METHODS NHBDs were killed by ether overdose. Kidney isografts (male Lewis rats [LEW]-->LEW) were transplanted orthotopically into bilaterally nephrectomized recipients 15, 30, 45, and 90 min after asystole to determine short-term survival patterns, which were compared to those of rats bearing kidneys from living donors (LDs, 0 min). Isografts and allografts (Fisher 344 rats-->LEW) from 45-min and 105-min NHBDs and from LD controls were placed in additional recipients in which contralateral native nephrectomy was performed on day 10 to allow the injured graft to recover from its ischemic insult. Serum creatinine, proteinuria, and graft morphology were assessed serially over a 24-week follow-up period. RESULTS Early survival and renal dysfunction of isografted rats correlated with the interval of donor cardiac arrest before transplantation. Long-term survival of recipients of kidneys from LDs and between 45-min and 105-min NHBDs was also significantly different (100% vs. 87% vs. 37% at 24 weeks, respectively, P

The catastrophic central injury of brain death (BD) has been shown to perturb significantly the function and structure of somatic organs in situ by rapid upregulation of inflammatory mediators and other acute phase proteins. 1,2 The tempo and intensity of acute rejection of heart, kidney, and liver allografts from such donors are accelerated after transplantation because the involved organs appears to trigger host alloresponsiveness as a continuum between nonspecific injury and specific immunologic activity. 3,4 Clinical data have confirmed that kidney grafts from brain-dead organ donors experience more frequent episodes of acute rejection after transplantation. 5 The lack of suitable donors and the increasing numbers of potential recipients have also resulted in the acceptance of “marginal” brain-dead donors, the organs of whom are at significant risk for primary nonfunction or primary delayed function (PDF) compared with those from living donors. PDF alone is associated with significant potential complications, an increase in retransplantation, and a higher recipient death rate. Such grafts, compromised not only by donor-associated conditions such as diabetes and hypertension, but also from insults surrounding the removal and storage, experience both an increased rate of acute and chronic rejection and significantly diminished survival. 6 Several factors have been implicated in the development of this complication, particularly ischemia–reperfusion (I/R), which appears to be an integral part of the syndrome of BD. 7 Because the state of BD occurs before organ retrieval, it is a potential risk factor for graft outcome after transplantation. As a result, means to improve the organ quality of cadaver donors before transplantation have been considered. Earlier attempts focused on altering the hormonal milieu. 8–10 Because the results of these approaches were disappointing, however, they were never introduced into clinical practice. 11 The objectives of the present study are to reassess whether other strategies of donor treatment at the time of BD improve organ quality by reducing inflammatory changes and subsequent associated acute host immune responsiveness. To prevent the nonspecific changes occurring within peripheral organs after the central catastrophe, two treatments were tested and their effects compared. First, a single dose of steroids was administered with induction of BD to reduce the release of inflammatory cytokines. Second, soluble P-selectin glycoprotein ligand (sPSGL) was given in similar fashion to prevent leukocyte adhesion to the inflamed vascular endothelium of the graft.

In contrast to the marked improvement in early results, the rate of long-term survival of solid-organ allografts has improved only slowly over the last few years despite the introduction of new and potent immunosuppressive protocols, better organ-preservation techniques, and advances in perioperative management. Because of the universal shortage of donor organs, less-than-ideal donors are being accepted, and grafts of potentially diminished quality are being used for transplantation. Therefore, recent interest has focused on the systemic changes in peripheral organs occurring in the donor during brain death (BD), during the period of preservation, and after placement in the recipient. It has become increasingly apparent that not only immunologic, but also nonimmunologic injuries, such as BD and ischemia-reperfusion injury, are important risk factors for short-term and long-term allograft outcome after transplantation. The systemic effects of this central catastrophe have led to an increasing number of experimental and clinical studies designed to elucidate the complexity of its resultant hemodynamic, metabolic, and neurohormonal alterations, as well as the morphologic changes and immunologic consequences to organs used for transplantation.

Background. The relatively few studies that have examined the systemic events after brain death have primarily involved large animals. For more precise definition of the physiology of this central catastrophe and its influence on peripheral organs, we have established a reproduceable model of gradual onset brain death in rats. Methods. The central injury is induced by graded inflation of a Fogarty catheter placed intracranially under EEG and blood pressure monitoring. The rats were mechanically ventilated for 6 hr before removal of their kidneys. Complications and mortality are discussed. Results. The majority (83%) of the 100 experimental animals could be used as organ donors. After a transient period of autonomic storm, the mean arterial blood pressure remained consistently between 80-100 mmHg, not appreciably different from controls. Despite normotension, the transplanted kidneys from brain dead donors showed a significantly longer interval to regain uniform cortical color and turgor than kidneys from control animals. Conclusions. We describe a controlled model of gradual onset brain death in the rat in which normotension can be sustained for several hours before the kidneys are removed for transplantation. Despite stable donor blood pressure, ischemia of peripheral organs may explain in part the increased incidence of delayed graft function of cadaver kidneys compared with those from living donors. This model is suitable for transplant-related studies involving organs from donors with irreversible central injury.

Dynamic imaging, in which the time dimension has a specific function in data (image) interpretation, is becoming increasingly important when contemplating endovascular aneurysm repair. Clinical parameters and complications, including proper sizing, successful aneurysm sac exclusion, optimal stent-graft design, endoleaks, graft migration, and stent fracture are beginning to be better understood through dynamic magnetic resonance, ultrasound, and dynamic computed tomography. The current practice using static 3-dimensional reconstructions for the planning and follow-up of aortic aneurysm endograft treatment will most likely evolve, and the use of dynamic aortic imaging will continue to increase. Validation of these imaging modalities in larger scale trials is needed.

Background. Marginal donor organs are used increasingly for transplantation. To define the influences of donor hypertension, we compared the behavior of kidney allografts from hypertensive and normotensive donors in an established rat model of chronic rejection. Methods. Donor hypertension was induced by partial occlusion of the right renal artery with a silver clip. After 10 weeks, the left kidney was removed and transplanted. Normotensive animals served as controls. All recipients were treated with a low dose of cyclosporine for 10 days (1.5 mg/kg). Blood pressure and proteinuria were determined weekly four times after transplantation. To examine the effects of donor hypertension on late events, grafts (n=6/time point) were examined morphologically and by quantitative reverse transcriptase-polymerase chain reaction analysis at serial intervals. Results. Recipients of kidneys from hypertensive donors developed systemic hypertension in contrast with normotensive controls (P

Donor brain death has been considered a significant risk factor for both early and late organ allograft dysfunction. This central injury not only evokes an upsurge of catecholamines with resultant peripheral tissue vasoconstriction and ischemia but also promotes release of hormones and inflammatory mediators that may also affect the organs directly. One of the resultant influences of these events is the rapid upregulation of the acute-phase adhesion molecules, the selectins. These initiate leukocyte adhesion to vascular endothelium and trigger subsequent cellular and molecular changes in the compromised tissues. An established F344 → LEW rat model of chronic rejection was used to examine ( 1 ) whether the initial inflammatory events that develop within kidney allografts from brain-dead donors could be normalized using a recombinant soluble form of P-selectin glycoprotein ligand and ( 2 ) whether amelioration of these early changes would alter the inexorable progression of chronic allograft rejection. Untreated living donor controls experienced unrelenting chronic rejection over time. This complex process was accelerated in brain-dead donor kidneys. Treatment with P-selectin glycoprotein ligand prevented the early inflammatory changes in the transplanted organs and their subsequent (200 d) functional and morphologic manifestations, particularly when the soluble ligand was administered both to the donor before organ removal and to the recipient after engraftment. This strategy of using a naturally occurring selectin ligand to prevent donor-associated chronic graft dysfunction may be of special clinical interest in cadaver donor transplantation.