Kidney transplants from living related donors having double inferior vena cava

We performed four living related kidney transplantations from donors with double inferior vena cava (D-IVC), in which the left kidney was selected in two cases and the right in two cases. By dissecting the right internal iliac vein and isolating the right external iliac vein, the surgical procedure of the recipient side was so devised as to avoid any complications. In one patient, the surgical procedure of the donor side was modified to extend the donor left renal vein by anastomosis of part of the donor IVC to the renal vein. In the other case, no special treatment was necessary due to the patient's slender physique. In all four cases, transplants were successfully performed. The following conclusions can be made from these results: If the donor has D-IVC, it is essential to carefully conduct pre-operative examinations including angiography and venography to investigate other possible anomalies and blood flow of the renal vein. In addition, the graft must be carefully selected so that it is not disadvantageous to the donor. If there is no disadvantage to the donor as to which kidney is selected, the kidney with the longer renal vein should be transplanted.     

A successful two-staged Fontan procedure for tricuspid atresia with bilateral superior venae cavae and left pulmonary arterial stenosis]

A 10-year-old boy with tricuspid atresia (type I-b), bilateral superior venae cavae and left pulmonary arterial branch stenosis was treated successfully by a two-staged Fontan procedure. At 7 years of age, left Glenn shunt was performed after creation of a communicating vessel between the right and left superior vena cava, using a GORE-TEX graft of 10 mm of diameter. Three years later, after having confirmed graft patency, Fontan procedure was achieved without any problems. We think the innominate vein creation by an artificial material was a key design for the following successful two-staged Fontan procedure in this case.     

Partial supracoronary translocation of the aortic valve prosthesis in a case of septic destruction of the aortic root

A patient with infective endocarditis and septic disruption of the anterior aspect of the aortic root was successfully treated by insertion of a prosthetic valve obliquely, above the right coronary ostium anteriorly and below the left posteriorly. The right coronary ostium was closed and the artery was bypassed by use of an autogenous saphenous vein graft. The procedure is considered to be an alternative to the more radical complete supracoronary translocation of the prosthetic valve, as described by Danielson and colleagues.     

Dialysis access in a patient with multiple central venous stenoses

We report a female patient, with obstructed right femoral and right brachiocephalic vein, narrowed left femoral vein, left brachiocephalic vein and superior vena cava, due to long-term catheterization for dialysis. Angioplasty and synthesized graft transplant were successfully performed. The new access withstood early cannulation only 3 days after the procedure. Angioplasty can ameliorate existing stenosis and enable permanent access creation, while an artificial graft may provide faster maturation than documented.     

Massive pulmonary embolism caused by internal iliac vein thrombosis with free-floating thrombus formation in the inferior vena cava

Nowadays, compression ultrasonography (CUS) is the gold standard for the routine diagnosis of deep venous thrombosis (DVT). The drawback of CUS is the low sensitivity concerning the diagnosis of isolated pelvic vein thrombosis, especially referring to isolated internal iliac vein and ovarian vein thromboses. Therefore, magnetic resonance (MR) venography has become a valuable alternative. We present the case of a 45-year-old female patient with a massive pulmonary embolism with the indication for thrombolytic therapy due to severe right ventricular overload. We were not able to detect a DVT in the lower limbs of this patient with CUS. However, further DVT workup by MR venography showed a free-floating thrombus formation originating from the right internal iliac veins into the inferior vena cava. Owing to the fact that this thrombus was free floating, surgical removal of the thrombus was scheduled and performed successfully. In some patients it might be important to look for so-called rare causes of pulmonary embolism, even when CUS of the lower limbs does not reveal any DVTs. The diagnostic procedure of choice for these patients seems to be MR phlebography, as iliac and pelvic veins can be evaluated without radiation exposure with this procedure.     

Variability of venous anatomy of rat testis: application to experimental testicular surgery.

The venous drainage of the testis of the laboratory rat was observed in 31 animals. The right testicular (internal spermatic) vein drained directly into the right common iliac vein in 77.4%, and into the inferior vena cava in 22.6% of the animals. The left testicular vein drained into the left common iliac vein in all animals, but in 90.3% there was also an accessory branch of the testicular vein draining into the left renal vein. These observations suggest that in the rat the exact anatomy of the venous drainage of each testis should be identified prior to undertaking any surgical procedure on the testis where the venous vasculature plays a major role such as testicular transplantation or the creation of an experimental varicocele.     

Anesthesia for pancreatoduodenectomy in a patient with history of coronary artery bypass graft surgery: determination of optimal surgical management by the graft clamping test

We report a case of a 72-year-old man undergoing pancreatoduodenectomy, who had a history of coronary artery bypass graft surgery using the right gastroepiploic artery. We intraoperatively used the graft clamping test, which was assessed via electrocardiography and transesophageal echocardiography, to verify patency of the right gastroepiploic artery graft. Because the graft clamping test was positive, first, we interposed the saphenous vein graft between the splenic artery and right coronary artery. The abdominal surgery was then successfully performed without any cardiac complications. In such a complicated case, anesthesiologists who are responsible for assessment of the graft clamping test play a crucial role in determining the optimal surgical procedure.     

Intra-arterial ECG leads of a positive P-wave potential during central venous catheterization

The application of a central venous catheter (CVC) is a routine procedure in anaesthesia and intensive care medicine. Although the procedure is generally carried out without complications, nevertheless numerous and, in part acute life threatening and lethal complications have been described. The complication rate during placement of a CVC is up to 12%. To ensure the correct position of the catheter, different methods may be used: for example the intravascular feeder of a positive P-wave of the ECG. In the case of a position check via the ECG (α-Card), the catheter's point serves as a unipolar electrode. The intraatrial ECG lead is used as a raised and heightened P-wave potential for the correct catheter position. In this case, we present a 65 year-old critically ill patient with an occlusion of the right superficial femoral artery and acute respiratory distress syndrome (ARDS) in whom a puncture trial of the right internal jugular vein was carried out. This was followed by the placement of the CVC intended for the right internal jugular vein which, however, turned out to be a direct puncture of the right carotid artery. Despite the inaccurate intra-arterial position, forwarding of the catheter showed a typical raised and heightened P-wave potential. The artery puncture was checked via a blood gas analysis and the artery blood pressure diagram tracing. The removal and correct placement of the CVC were achieved without any problems. These findings emphasize the P-wave potential in the ECG feeder does not correlate with the transition from the superior vena cava to the right atrium. Consequently, this does not preclude an intra-arterial malposition.     

Caval extension of the right renal vein in cadaveric renal transplantation using the ETS 45 endoscopic stapler

A major technical difficulty encountered with the transplantation of a cadaveric right kidney is due to the short right renal vein. The transplant surgeon usually has two different options to deal with this: the first is to mobilize the external iliac vein, ligating the internal iliac vein and the small retroiliac veins, while the second option is to increase the length of the right renal vein. Right renal vein extension is usually preferred because it is easier to work with. The technique used was to construct a conduit with the vena cava that extends the cadaveric right renal vein using an endoscopic stapler (Ethicon Endopath Linear Cutter ETS45, cod. TSW 45) for thin/vascular tissues. This procedure has been used successfully in 11 of our 155 transplanted patients. We have seen no vascular complications as a result of the stapled conduit of the vena cava. We conclude that the endoscopic stapler for thin/vascular tissues is safe and easy to use in right renal vein extension.     

A simultaneous operation of CABG and bilateral femoropopliteal bypass: report of a successful case

A 62-year-old man with both coronary artery disease and leg ischemia was successfully treated with a combined revascularization procedure. Coronary artery bypass grafting (CABG) was carried out using in situ left internal thoracic artery and right gastroepiploic artery grafts, and bilateral femoropopliteal bypass grafting were performed reversed saphenous vein grafts simultaneously. The patient recovered well and experienced neither angina nor intermittent claudication.     

Nonsurgical retrieval of intra-cardiovascular catheter fragments

Migrated intra-cardiovascular fragments from broken catheters were retrieved transvenously in 6 cases. In all of these cases, the catheters had been used for total parenteral nutrition. The catheter fragments were lodged in the pulmonary artery in 3 cases and in the right atrium in the others. A basket-type grasping forceps modified for this retrieval technique was inserted via the subclavian vein, femoral vein or basilic vein percutaneously. The migrated catheter fragments were removed successfully without any clinical complications in all 6 cases. Appropriate evaluation of the lodging site and length of the fragment, and careful examination of general condition should be carried out prior to this procedure. This noninvasive maneuver is simple, safe and reliable, and can be promptly. It is considered to be a reliable method of choice in cases of migrated catheter fragment.     

Thrombectomy before hepatic resection for hepatocellular carcinoma with a tumor thrombus extending to the inferior vena cava

Tumor thrombi of hepatocellular carcinoma occasionally invade into the inferior vena cava (IVC) through the hepatic vein. Once the tumor thrombus is dislodged, severe and lethal complications, such as pulmonary infarction, can develop. We successfully operated on a hepatocellular carcinoma (HCC) patient with a tumor thrombus extending to the IVC through the right hepatic vein. To avoid dislodging the thrombus during surgery, a thrombectomy using selective hepatic vascular exclusion was performed before a hepatic resection, which is the most dangerous procedure to dislodge the thrombus.     

A portal vein branch embolization as a method of preparation for liver resection

The results of preoperative transcutaneous transhepatic embolization of portal vein (PTTEPV) were analyzed in 86 patients, suffering malignant hepatic tumors. Depending on a planned hepatic resection (HR) volume there was conducted embolization of a right lobar portal vein (in 45 patients), right vein with a vein of C(IV) segment (in 32), lobar portal vein with anterior right vein (in 9). In 3-4 weeks after PTTEPV there was noted the enhancement of ratio of a planned residual hepatic volume/total hepatic volume from 16.3 to 27.5%, permitting to perform HR successfully in these patients. In 4 (4.7%) patients HR was not performed because of progressing of the tumor development or a total thrombosis of portal vein. The data obtained witness, that PTTEPV constitute an effective method of the patients preparation for HR while presence of a planned small residual hepatic volume.     

Pull-through technique with pincer tactics for stent placement in severe superior vena cava syndrome

The pull-through technique is an interventional radiological procedure used when an occluded lesion cannot be traversed from one direction. To pass the lesion, a long guidewire is traversed from the opposite side and pulled through the ipsilateral sheath using a snare wire. The present report describes a case of severe superior vena cava syndrome treated by stent placement using a pull-through technique with pincer tactics. We successfully placed a stent in the occluded right internal jugular vein to the superior vena cava using a bilateral approach by snaring a guidewire in the right subclavian vein.     

A surgical technique for correction of total anomalous pulmonary venous drainage

A technique was employed successfully for correction of total anomalous pulmonary venous drainage into the upper right superior vena cava. A J-shaped right atriotomy was performed; the posterior flap was sutured to the anterior border of a previously enlarged atrial septal defect. The right superior vena cava was divided above the site of drainage of the pulmonary veins, and its proximal opening closed with a suture. The pulmonary venous return was directed to the left atrium in this way. The right atrial-right superior vena caval continuity was then reestablished by an anastomosis between the previously opened right atrial appendage and the distal end of the right superior vena cava. Finally the remaining atriotomy was closed. The azygos vein must be ligated to avoid systemic unsaturation. For correction of anomalous pulmonary venous drainage into the azygos vein with this technique, ligature of the azygos vein must be placed distally to the site of anomalous drainage. Three patients, aged 2 months, 7 years, and 16 years, respectively, with different anatomic types of the anomaly, were successfully operated on with this procedure. Findings displayed from the postoperative hemodynamic, echocardiographic, and clinical evaluation are encouraging, after a follow-up period that ranges from 4 months to 4 years. The advantages of the repair are discussed.     

Inferior vena cava reconstruction using fresh inferior vena cava allograft following caval resection for leiomyosarcoma: midterm results

We present a 56-year-old woman affected by a large leiomyosarcoma originating from the suprarenal inferior vena cava (IVC). A computed tomography (CT) scan revealed near obstruction of the IVC and involvement of the right renal vein. The patient underwent successful en bloc resection of the tumor, right kidney, right adrenal gland, and IVC. Caval reconstruction was performed using a non-type specific allograft, followed by left renal vein re-implantation. The patient tolerated the procedure well without any complications. The use of an IVC allograft allowed for continued graft patency, without the need of immunosuppression or long-term anticoagulation. However, local recurrence did occur.     

腹腔镜左肝优先原位模块化右半肝加尾状叶切除术治疗Ⅲa型肝门部胆管癌初步体会

目的总结腹腔镜左肝优先原位模块化右半肝加尾状叶切除术治疗Ⅲa型肝门部胆管癌的经验。 方法回顾性分析2020年6月在河北医科大学第二医院肝胆胰腺外科进行腹腔镜左肝优先原位模块化右半肝加尾状叶切除术患者的临床资料。 结果患者顺利完成手术，手术时间390 min，术中出血量约600 ml，术中输注红细胞0.5 U、血浆600 ml。术后无出血、胆瘘、胃肠瘘、胆管狭窄等并发症，顺利出院。术后病理报告显示Bismuth Ⅲa型肝门部胆管癌。 结论腹腔镜左肝优先原位模块化右半肝加尾状叶切除术对于Bismuth Ⅲa型肝门部胆管癌是安全、可行的。优势：符合"no-touch"和"en-block"肿瘤外科基本原则，减少术中操作牵拉、挤压肿瘤；处理第三肝门和第二肝门时，助手向左侧牵拉左半肝可以有效增加手术操作空间，方便术者"考古式"显露、处理肝短静脉和右肝静脉。     

Auxiliary partial orthotopic living donor liver transplantation for a child with congenital absence of the portal vein.

Congenital absence of the portal vein (CAPV) is a rare malformation of the mesenteric vasculature in which visceral venous blood bypasses the liver, completely draining into the systemic circulation through a congenital porto-systemic shunt. Liver transplantation has rarely been indicated for patients with this disease. We present a child with CAPV who was managed successfully by living donor auxiliary partial orthotopic liver transplantation (APOLT), while preserving the right lobe of the native liver. In conclusion, APOLT for patients with CAPV is a feasible and ideal procedure because portal vein (PV) diversion is not necessary.     

A modified Fontan operation in the presence of a supracardiac total anomalous pulmonary venous connection

We report a case of 2-year-old girl with asplenia syndrome who successfully underwent modified Fontan procedure and concomitant repair of supracardiac total anomalous pulmonary venous connection (TAPVC). The preoperative diagnosis included a common atrioventricular canal (type C), a double outlet right ventricle, a common atrium, common atrioventricular valve regurgitation, pulmonary stenosis, and a bilateral superior vena cava (SVC). Cardiac catheterization revealed a Qp/Qs of 1.3, mean PA pressure of 16 mmHg and an Rp of 1.3. The TAPVC drained to left SVC (LSVC) at a position proximal to the hemiazygos vein with an ostium of 5 mm in diameter. The LSVC was divided distal to its connection to the common pulmonary vein (CPV). The TAPVC ostium was cut back into the CPV, then it was anastmosed with posterior aspect of the atrial wall in an effort to provide a wide anastomosis. The postoperative course was uneventful and the patient was discharged from hospital on the 35th postoperative day.     

Remoção endovascular percutânea de cateter totalmente implantável com migração intracardíaca em criança com leucemia linfoblástica aguda

A 2‐year‐old boy with acute lymphoblastic leukemia was presented with peripherally inserted central catheter dysfunction. Radiological examinations revealed a catheter remnant in the right atrium extending into pulmonary vein. The catheter remnant was successfully removed from the right atrium by percutaneous endovascular intervention without any complications.