Total Pancreatectomy with Celiac Axis Resection and Hepatic Artery Restoration Using Splenic Artery Autograft Interposition.

Although the indication of locally advanced pancreatic cancer with arterial involvement is controversial, the outcome of the patients with such disease treated by combined resection and reconstruction of the invaded artery has improved recently. For pancreatic body carcinoma invading the celiac axis, distal pancreatectomy with celiac axis resection has been safely performed. However, in case of pancreatic body carcinoma with involvement of the celiac axis, the common hepatic artery and the gastroduodenal artery, margin-negative resection requires total pancreatectomy with celiac axis resection and restoration of hepatic arterial flow. Here, we describe an interposition grafting technique using the splenic artery harvested from the resected specimen. This technique is effective and may widen the resectability of pancreatic cancer in selected patients.

Comparative morphometric analysis of 5 interpositional arterial autograft options for adult living donor liver transplantation.

UNLABELLED: In living donor liver transplantation, the right-sided graft presents thin and short vessels, bringing forward a more difficult anastomosis. In these cases, an interpositional arterial autograft can be used to favor the performance of the arterial anastomosis, making the procedure easier and avoiding surgical complications. OBJECTIVE: We compared the inferior mesenteric artery (IMA), the splenic artery (SA), the inferior epigastric artery (IEA), the descending branch of the lateral circumflex femoral artery (LCFA), and the proper hepatic artery (PHA) as options for interpositional autograft in living donor liver transplantation. METHOD: Segments of at least 3 cm of all 5 arteries were harvested from 16 fresh adult cadavers from both genders through standardized dissection. The analyzed measures were proximal and distal diameter and length. The proximal diameter of the RHA and the distal diameter of the SA, IMA, IEA and the LCFA were compared to the distal diameter of the RHA. The proximal and distal diameters of the SA, IEA and LCFA were compared to study caliber gain of each artery. RESULTS: All arteries except the IMA showed statistical significant difference in relation to the RHA in terms of diameter. Regarding caliber gain, the arteries demonstrated statistical significant difference. All the harvested arteries except PHA were 3 cm in length. CONCLUSION: The IMA demonstrated the best compatibility with the RHA in terms of diameter and showed sufficient length to be employed as interpositional graft. The PHA, the SA, the IEA and the LCFA presented statistically significant different diameters when compared to the RHA. Among these vessels, only the PHA did not show sufficient mean length.

Splenic artery use for arterial reconstruction in pancreatic surgery.

BACKGROUND: Extended resections in the upper GI tract, especially for pancreatic malignancies, can require resection of the hepatic or superior mesenteric artery. Besides venous or allogenous grafting, the splenic artery can be used for reconstruction in both positions. PURPOSE: We hereby describe the different technical possibilities of interposition or transposition to use the splenic artery for restoration of arterial perfusion of the liver or the small bowel following resection of the hepatic or superior mesenteric artery, respectively. CONCLUSION: The use of the splenic artery is a convenient and appropriate possibility to reconstruct the hepatic or superior mesenteric artery in pancreatic resection with regard to interposition and especially transposition of this vessel. It should be considered in patients suitable to undergo these procedures to extend resectability in pancreatic cancer surgery.

Splenic artery transposition graft usage for the supply of the right hepatic artery: a case report.

Hepatic artery aneurysms are responsible for 12% to 20% of all visceral arterial aneurysms. Because most patients are asymptomatic, this disease is generally diagnosed incidentally during radiologic examination. Aneurysm rupture develops in 14% to 80% of cases, depending on the aneurysmatic segment's diameter and location, as well as other etiologic factors. Mortality rates associated with rupture range between 20% and 70%. Thus, early diagnosis and timely initiation of medical interventions are critical to improve survival rates. Here, we present a male patient, age 69 years, with a hepatic artery aneurysm that was detected incidentally. The 3-cm aneurysm was detected on contrast-enhanced computed tomography and extended from the common hepatic artery to the hepatic trifurcation. A laparotomy was performed using a right subcostal incision. After dissection of the hepatoduodenal ligament, the common, right, and left hepatic arteries, as well as the gastroduodenal artery, were suspended separately. Then, the aneurysmatic hepatic artery segment was resected, and the gastroduodenal artery stump was ligated. An end-to-end anastomosis was formed between the left and common hepatic arteries, followed by an end-to-end anastomosis formed between the right hepatic artery and splenic artery using a splenic artery transposition graft. Postoperative follow-up examinations showed that both hepatic arterial circulations were good, and no splenic infraction had developed.

Revascularization of the celiac and superior mesenteric arteries after operative injury using both splenic artery and saphenous graft.

We report a case of iatrogenic resection of both the superior mesenteric artery (SMA) and celiac artery during left nephrectomy and adrenalectomy. A 47-year-old woman was diagnosed with a large adrenal tumor and underwent a laparoscopic left adrenalectomy that was converted to open adrenalectomy and nephrectomy as a result of a bulky tumor. Both the SMA and celiac artery were inadvertently cut at their origin because of adherence of the tumor to the aorta. Both arteries were revascularized by anastomosing the distal splenic artery to the aorta after performing splenectomy to revascularize the celiac circulation and using an autologous saphenous vein graft to revascularize the SMA. The patient had no postoperative complications. To our knowledge, this is the first description of use of the splenic artery for celiac revascularization.

Reconstruction of the common hepatic artery at the time of total pancreatectomy using a splenohepatic bypass.

Arterial involvement by a periampullary adenocarcinoma is often a contraindication for resection, since an R0 resection cannot be achieved. This is usually observed in cases with involvement of the superior mesenteric artery. Involvement of the common hepatic artery, however, requires a bypass procedure if the gastroduodenal artery was divided during the resection. In such cases, the splenic artery can be used as an inflow-source provided that there is no stenosis of the celiac trunk and the splenic blood flow is preserved via the short gastric arteries. We describe a technique used in four cases for the reconstruction of the common hepatic artery following a segmental resection of this vessel en bloc with a periampullary tumor during pancreatectomy. The inflow is maintained by a splenohepatic bypass using the splenic artery.

Intraoperative hemodynamic assessment of gastroepiploic artery and saphenous vein bypass grafts: a comparative study.

OBJECTIVE: Blood flow characteristics of right gastroepiploic artery and saphenous vein conduits were compared during bypass surgery. METHODS: This study is based on a consecutive series of 97 patients undergoing a bypass graft to the right coronary artery, posterior descending artery, or posterolateral branch using either a pediculated right gastroepiploic artery (n = 52) or a saphenous vein (n = 45) bypass graft. Flows and velocity profiles were measured with an 8-MHz pulsed-wave Doppler ultrasound flowmeter. Thorough flow measurements were made (1) after cessation of cardiopulmonary bypass and (2) before chest closure. RESULTS: At the end of cardiopulmonary bypass, flow in the right gastroepiploic artery (59. 0 +/- 6.7 mL/min) did not differ (P =.08) from flow in the saphenous vein (46.1 +/- 2.7 mL/min). Mean trace velocity was 11.9 +/- 0.7 cm/s in the right gastroepiploic artery and 11.6 +/- 0.8 cm/s in the saphenous vein (P =.80), but peak systolic velocity was 29.4 +/- 1.2 cm/s for the right gastroepiploic artery and 23.1 +/- 1.3 cm/s for the saphenous vein (P <.001). Likewise, before chest closure, flow was 57.1 +/- 4.7 mL/min in the right gastroepiploic artery and 46.5 +/- 4.0 mL/min in the saphenous vein (P =.10), mean velocity was 12. 9 +/- 0.7 and 11.6 +/- 0.8 cm/s, respectively (P = .22), and systolic peak velocity was 30.0 +/- 1.2 and 22.3 +/- 1.2 cm/s, respectively (P < .001). CONCLUSIONS: There were no flow differences between right gastroepiploic artery and saphenous vein grafts implanted into the same coronary bed in comparable groups of patients. Waveform shape of the right gastroepiploic artery grafts was characterized by a wider spectral dispersion resulting in a higher maximal frequency.

Results of using the recipient's splenic artery for arterial reconstruction in liver transplantation in 23 patients.

BACKGROUND: Arterial reconstruction is essential in liver transplantation. In some patients there may be an inadequate flow as a result of stenosis, intimal dissection, or anomalies of the hepatic artery. METHODS: This study analyzes our experience with 23 patients in whom arterial anastomosis was performed using the splenic artery due to the inadequacy of the hepatic artery. During the same period an aortoiliac conduit was used in 12 liver transplantations due to the same problem. RESULTS: No splenic infarction, pancreatitis, or other related complications were found. Artery thrombosis developed in only two patients in the aortoiliac conduit group. One- and three-year patient actuarial survival were 78% vs. 80% and 72% vs. 80%, respectively, for the splenic artery group and the aortoiliac conduit group. CONCLUSIONS: Anastomosis with the splenic artery is an alternative in liver transplantation and is particularly suitable when splenomegaly is present.

Free splenic artery used in aortocoronary bypass.

Many alternative bypass conduits for coronary revascularization have been used since the introduction of the saphenous vein. The internal mammary artery has demonstrated superior long-term patency rates compared with vein grafts. Other arterial grafts previously investigated include the right gastroepiploic artery, inferior epigastric artery, radial artery, and splenic artery. This case reports bypass using a free splenic artery and a pedicled right gastroepiploic artery, each with successful postoperative patency.

Clinical alternative bypass conduits and methods for surgical coronary revascularization.

Poor quality or inadequate length of venous and mammary conduits, or both, a severely calcified or atherosclerotic aorta, or diffuse coronary atherosclerosis are situations cardiovascular surgeons will be facing with increasing frequency. These conditions are more common to the increasing number of patients requiring reoperation for advancing disease and to the growing number of older patients requiring operation. Decisions will be made preoperatively or intraoperatively about the technique to be used. Extensive use of the internal mammary arterial graft, such as bilateral internal mammary artery bypass, sequential use of the mammary artery and use of a free internal mammary artery graft, are excellent choices. These methods can overcome some of the difficult situations of the severely calcified atherosclerotic aorta or the absence of adequate venous conduits. Coronary arterial bypass using the inverted internal mammary conduit has too low a flow to be considered. Composite conduits will help gain the length needed to solve both the inadequate length problem and the severely diseased aorta. Little clinical experience is reported to date. These methods should only be used when nothing else is available. The innominate to coronary arterial bypass and the left subclavian to coronary arterial bypass can help solve the problem of the severely atherosclerotic aorta. The coronary to coronary arterial bypass has been used to solve both the severely diseased aorta and the short conduit situation. These methods, while ingenious, are supported only by occasional isolated clinical experiences. A large number of researchers have done extensive work on the selective retrograde coronary venous bypass grafting, but the last published article of any clinical importance dates back to 1979 and this suggests that other alternatives may be better. This technique should be used as a last resort. The surgical arteriovenous fistula has been clinically applied during the coronary artery bypass procedure. The nonconduit revascularization technique of coronary artery endarterectomy is needed in the armamentarium of the surgeon. This technique is not ideal but presently has better results than intraoperative transluminal coronary angioplasty and far better results than laser angioplasty. These methods may be useful to solve the diffuse coronary arterial problem, but sequential grafting techniques should be considered first.

The possibility of using celiac trunk branches as coronary artery bypass grafts.

The internal mammary artery has proved to be superior to the saphenous vein for coronary artery bypass grafting, because of its arterial nature and closer approximation in size to the coronary arteries. But the internal mammary artery cannot reach the posterior surface of the heart as a pedicled graft. Two suitable intra-abdominal grafts can reach that surface, viz. the right gastroepiploic artery and the splenic artery. In experiments on eight dogs (weight 9-13.5 kg), the gastroepiploic artery was found to be too small for coronary artery anastomosis, and therefore the splenic artery was used. The size approximation with coronary artery (diameter less than 1 mm) was good. Four dogs survived the month of the study. In two of them the anastomosis was patent, in another the splenic artery was patent despite occlusion of the anastomosis, and in the fourth dog both anastomosis and graft were thrombosed. The possibility of using visceral arterial grafts in coronary surgery is discussed.

[Transplantation of small segments of the pancreas with microvascular connections as one of the methods of treatment of diabetes mellitus]. / Transplantatsiia malykh segmentov podzheludochnoi zhelezy na mikro- sosudistykh sviaziakh kak odin iz metodov lecheniia sakharnogo diabeta.

Analysed were 3700 case records of the patients suffering from diabetes mellitus in order to establish direct indications for transplantation of small pancreatic segments. In procurement of the pancreas from 86 cadavers, it was established, that the subjects at the age under 40 were the ideal donors. In 34 experiments, the possibility of the performance of adequate conservation of the pancreas up to 6-8 h by the perfusion-free hypothermic method, intraorganic normothermal perfusion, transplant placing into the continuously oxygenated perfluoran solution or diluted blood, or in combined use of the two latter methods is shown. The results of 40 experiments on the dogs indicate that preservation and transplantation of 1/4-1/8 of the pancreatic mass are sufficient for maintaining normoglycemia.

Use of the splenic and hepatic arteries for renal revascularization.

During a 16-year period at the Massachusetts General Hospital 77 patients underwent 79 procedures (29 hepatorenal bypasses, 50 splenorenal arterial anastomoses) for treatment of renovascular hypertension, renal preservation, or both. The procedure was chosen primarily to avoid a diseased or scarred aorta in 41, to allow a staged approach to bilateral renal artery stenoses or multiple vascular lesions in 17, as a "lesser operation" for five poor-risk patients, for complex problems including trauma, mycotic aneurysm, aortic dissection, thoracoabdominal aneurysm, and renal artery aneurysm in five, and as the procedure of choice in 11 patients. The perioperative mortality rate was 6% for the 77 patients studied. No hepatic dysfunction was seen. Deterioration of renal function occurred on three occasions but only in patients with bilateral simultaneous repair. Cure or improvement of hypertension was achieved in 52 of 63 patients and renal function preserved or improved in 67 of 77 patients. Long-term functional results remain good during follow-up periods up to 14 years. Our experience indicates that use of the hepatic or splenic artery may provide a safe and largely successful alternative for renal revascularization in selected circumstances.

Acute bilateral renal artery occlusion. Revascularization with the splenic artery.

Although acute renal artery occlusion usually leads to kidney necrosis, preexisting collateral vessels may occasionally preserve the organ long enough to permit revascularization. This principle was demonstrated in a patient in whom bilateral acute renal artery occlusion developed following repair of an aortoduodenal fistula. Approach to the aorta for primary revascularization was interdicted by extensive scarring. Accordingly, bilateral renal artery revascularization was successfully effected with the use of the splenic artery and reversed saphenous vein grafts through extra-anatomic planes. This experience demonstrates the importance of an aggressive diagnostic and therapeutic approach to acute renal artery occlusion, as well as the usefulness of the large-caliber, lengthy, disease-free, dispensable splenic artery as a revascularization source.

Renal revascularization after intrarenal implantation of the splenic artery with a distal arteriovenous fistula.

Renal revascularization by splenic artery implantation was performed in 5 dogs using a temporary arteriovenous fistula in the distal end of the implanted artery for the purpose of increasing the blood flow and counteracting the thrombus formation in the artery. Following creation of renal artery stenosis, the revascularization process was evaluated by serial consecutive splenic arteriographies and by estimation of blood flow through the implanted arteries. The experimental animals survived occlusion of the ipsilateral renal artery and contralateral nephrectomy with maintenance of a reasonably good renal function. The present study also indicates a facilitation of a vascularization from the implanted artery when the initial thrombus formation within the artery was prevented by creation of such a fistula.