Surgical Technology International
38th Edition
Contains 63 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.
June 2021 - ISSN:1090-3941
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Surgical Implantation Techniques of Modern Continuous Flow Ventricular Assist Devices
Gaik Nersesian, Evgenij Potapov, MD, Christoph T. Starck, MD, Timo Z. Nazari-Shafti, MD, Markus Kofler, MD, Jörg Kempfert, MD, Volkmar Falk, MD, Karel M. Van Praet, MD, Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
1382
Implantable left ventricular assist devices (durable LVADs) have dramatically improved mortality and morbidity in patients with advanced heart failure. Originally designed as a bridge or candidacy to heart transplantation, the indications extend toward permanent support and palliation. Modern durable continuous flow LVADs are small, commercially available, and allow for different surgical approaches to a wide range of patients with various cardiac pathologies. We will review different surgical implantation techniques of modern continuous flow LVADs, as well as specific aspects of preoperative patient evaluation and planning.
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The Skirt and Collar of The Valsalva Graft: One Dress Fits All
Raffaele Scaffa, MD, Luca Weltert, MD, Andrea Salica, MD, Ruggero De Paulis, MD, Professor of Heart Surgery, Department of Cardiac Surgery, European Hospital, Rome, Italy
1390
In the original pre-formed Valsalva graft, the skirt is the defining feature. It is a self-expanding portion, obtained by 90° rotation of the Dacron fabric corrugation with respect to the rest of the graft. Due to this manufacturing feature, the skirt length is equal to the graft diameter and, once pressurized, it expands by 25-30% (up to 10 mm) from the nominal size. Proximal to this bulged portion, a small collar completes the prosthesis. By virtue of this anatomical design, the Valsalva graft is recommended for most aortic root surgeries including valve-sparing and Bentall procedures.
The skirt, by recreating the pseudo-sinuses, represents the key feature of the graft when used for aortic valve-sparing procedures (remodeling and reimplantation). However, in the Bentall procedure, the graft collar is an important feature because it is useful to attach the Valsalva graft to the valve prosthesis sewing ring when making a valved conduit. Moreover, once the graft is pressurized, the whole volume of the skirt better accommodates the struts and the leaflets of biological and mechanical prostheses. Furthermore, the expanded skirt reduces the distance and the tension on the coronary button anastomosis, increasing safety and possibly reducing complication rates.
This review demonstrates the versatility of the Valsalva graft in various scenarios of aortic root surgery, with special emphasis on different uses of the skirt and the collar.
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State of the Art Review: Surgical Treatment of Acute Type A Aortic Dissection
Leonard Pitts, Matteo Montagner, MD, Markus Kofler, MD, Karel M. Van Praet, MD, Roland Heck, MD, Semih Buz, MD, Stephan D. Kurz, MD, MPH, Simon Sündermann, MD, PhD, Volkmar Falk, MD, PhD, Jörg Kempfert, MD, PhD, Associate Professor, Matthias Hommel, MD, German Heart Center Berlin, Germany
1413
Acute type A aortic dissection (ATAAD) is a life-threatening event that requires immediate surgical treatment. Improvements in surgical treatment, graft technology, organ protection and imaging techniques have led to improved clinical outcomes. Individualized treatment concepts have emerged based on more advanced planning tools that allow for a tailored approach even in complex situations such as multi-level malperfusion. This review provides an overview of the current surgical treatment of ATAAD, focusing on new disease classifications, preoperative computed tomography angiography (CTA) assessment, new prosthesis and stent technologies, and organ-protection strategies.
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MINI OPCAB Operation: Surgical Technique
Federico J. Benetti, MD, Natalia Scialacomo, MD, Benetti Foundation, Rosario, Argentina, Gustavo Mazzolino, Ing, Invita Science Corp, Port St. Lucie, FL, USA
1400
Introduction: We describe how to perform left internal mammary artery (LIMA) bypass to the left anterior descending (LAD) artery, the so-called MINI Off-pump Coronary Artery Bypass (MINI OPCAB).
Materials and Methods: We included patients with a demonstrated predominant ischemia related to the LAD territory. Of 70 patients who were operated upon at the Benetti Foundation, 10 received hybrid revascularization.
Surgical Technique: The patient is prepared as for a standard coronary bypass operation through sternotomy. The sternum is opened to the 3rd or 4th intercostal space depending on the anatomy, and a retractor is put in place. The left mammary artery is generally dissected to about 8 cm and isolated without the veins. Importantly, the angle of the superior part, where the mammary artery is attached to the sternum, needs to be below 20% to avoid any potential kinking. The pericardium is cleaned to identify the area of the pulmonary artery. The pericardium is opened to the apex and towards the right to around 5 to 6 cm initially. In most cases, the area of the LAD can be seen and the potential area of the anastomosis is defined. The patient is heparinized and the LAD is occluded with 5-0 Proline. A mechanical stabilizer is put in place and the anastomosis is performed. When the bypass is finished, and before sutures are tied, the stitches of 5-0 polypropylene around the artery are released, along with the clamp of the mammary artery; the anastomosis is then tied. The mechanical stabilizer is removed, the stitches of the pericardium are released and the flow of the graft is measured, while ensuring that there is no kinking. If the flow and Pulsatility and Resistance (PR) are acceptable, the mammary is fixed with 2 stitches of 7-0 polypropylene on both sides around 1 cm from the anastomosis. The heparin is reverted with protamine and a drain is put in place, while taking care to avoid any chance of touching the mammary artery or the anastomosis. The sternum is closed with 1 or 2 wires.
Results: Operative mortality in this series was 0%; one patient was converted to sternotomy off-pump (1.4%). None of the grafts were revised after measurement with a Medistim system (Medistim ASA, Oslo, Norway). Fifty five patients (79%) were extubated in the operating room The average hospitalization stay was 60 hours (SD 17, 95% CI). Sixteen patients who underwent the LIMA-to-LAD procedure were restudied, with 100% patency. At 144 months, 82% of the patients were alive and 68% were asymptomatic.
Conclusion: Additional clinical experience is required to be able to reproduce this operation on a large scale and expand the MINI OPCAB operation in hybrid revascularization.
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Blood Flow Quantification in Peripheral Arterial Disease: Emerging Diagnostic Techniques in Vascular Surgery
Stefan Engelhard, MSc, Lennart van de Velde, MSc, Erik Groot Jebbink, PhD, Michel M.P.J Reijnen, MD, PhD, Professor, Rijnstate, Arnhem, The Netherlands, Michel Versluis, PhD3, Professor, University of Twente, Enschede, The Netherlands, Kartik Jain, PhD 4, Assistant Professor, University of Twente, Enschede, The Netherlands, Jos Westenberg, PhD 5, Associate Professor, Department of Radiology, Cardiovascular Imaging Group, Leiden University Medical Center, Leiden, The Netherlands, Clark J Zeebregts, MD, PhD 6, Professor, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
1410
The assessment of local blood flow patterns in patients with peripheral arterial disease is clinically relevant, since these patterns are related to atherosclerotic disease progression and loss of patency in stents placed in peripheral arteries, through mechanisms such as recirculating flow and low wall shear stress (WSS). However, imaging of vascular flow in these patients is technically challenging due to the often complex flow patterns that occur near atherosclerotic lesions. While several flow quantification techniques have been developed that could improve the outcomes of vascular interventions, accurate 2D or 3D blood flow quantification is not yet used in clinical practice. This article provides an overview of several important topics that concern the quantification of blood flow in patients with peripheral arterial disease. The hemodynamic mechanisms involved in the development of atherosclerosis and the current clinical practice in the diagnosis of this disease are discussed, showing the unmet need for improved and validated flow quantification techniques in daily clinical practice. This discussion is followed by a showcase of state-of-the-art blood flow quantification techniques and how these could be used before, during and after treatment of stenotic lesions to improve clinical outcomes. These techniques include novel ultrasound-based methods, Phase-Contrast Magnetic Resonance Imaging (PC-MRI) and Computational Fluid Dynamics (CFD). The last section discusses future perspectives, with advanced (hybrid) imaging techniques and artificial intelligence, including the implementation of these techniques in clinical practice.
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Surgical Treatment of Ischemic Dilative Cardiomyopathy by Ventricular Restoration
Guglielmo Stefanelli, MD, Clorinda Labia, MD, Marco Meli, MD, Department of Cardiac Surgery, Hesperia Hospital, Modena, Italy, Andrea Barbieri, MD, Professor of Cardiology, University of Modena e Reggio Emilia, Modena, Italy, Luca Weltert, MD, Professor of Medical Statistics, Saint Camillus University of Health Sciences, Roma, Italy
1393
Patients with symptomatic post-ischemic dilative myocardiopathy of the left ventricle require, in selected cases, an operation to reshape and reduce the volume of the left ventricular chamber, in addition to surgical myocardial revascularization and mitral valve repair, with the aim of prolonging survival, improving the quality of life and minimizing the need for re-hospitalizations related to recurrent heart failure. This procedure is called surgical ventricular restoration (SVR), and is a useful tool for the treatment of heart failure patients as an alternative to heart transplant. This article provides an overview of surgical ventricular restoration for the treatment of dilative ischemic myocardiopathy. It illustrates several surgical options, describes the operative details, and discusses the correct indications for the procedure. Finally, an interesting protocol for one-step cell therapy during SVR is proposed, as an innovative treatment for heart failure patients.
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3D Printing in Cardiovascular Disease: Current Applications and Future Perspectives
Emanuele Verghi, MD, Antonio Nenna, MD, PhD(S), Ciro Mastroianni, MD, PhD, Mario Lusini, MD, PhD, Massimo Chello, MD, Professor, Cardiac Surgery, Università Campus Bio-Medico di Roma, Rome, Italy, Vincenzo Catanese, MD, Nunzio Montelione, MD, PhD, Associate Professor, Francesco Stilo, MD, PhD2, Associate Professor, Francesco Spinelli, MD, Professor, Vascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
1422
Three-dimensional (3D) printing is emerging as an innovative tool for a tailored approach to endovascular or open procedures. The efforts of different specialists and data analysis can be used to fabricate patient-specific implants, which might have significant impact even in life-saving procedures such as aortic dissections or aortic arch aneurysm. 3D printing is gradually changing the traditional pattern of diagnosis and treatment. This innovative approach allows a perfect match between the patient's anatomy and the prosthetic graft, ideally resulting in better hemodynamics and improved long-term patency related to reduced turbulent flow. Future applications of 3D printing in the cardiovascular field combined with tissue engineering will enhance the therapeutic features of bioprinted tissues and scaffolds for regenerative medicine. This review will summarize the clinical significance of 3D printing in cardiovascular disease, exploring current applications, translational outlooks and future perspectives.
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Latest Developments in Robotic Percutaneous Coronary Intervention
Felix J. Hofmann, MD, Oliver Dörr, MD, Florian Blachutzik, MD, Niklas Boeder, MD, Stanislav Keranov, MD, Alessa Köhne, Christian Hamm, MD, Holger M. Nef, MD, University of Giessen, Giessen, Germany, Albrecht Elsässer, MD, Klinikum Oldenburg, Germany, Simon Hofmann, University of Applied Sciences, Germany, Helge Möllmann, MD, St.-Johannes-Hospital Dortmund, Germany
1405
Interventional cardiovascular medicine has seen constant progress over the last few decades. Since the first angiograms and percutaneous transluminal coronary angioplasty were carried out, this progress has been tremendous and has led to a substantial decline in cardiovascular morbidity and mortality. The purpose of this article is to report and review the latest developments and evidence in robotics-assisted percutaneous coronary intervention (rPCI) and its potential future applications, opportunities, and limitations.
Contemporary evidence shows that rPCI can lead to a significant reduction in radiation exposure as well as medical hazards for cardiologists. Rates of device and procedural success remain high and there is no evidence of a disadvantage for the patient. The accuracy of implantation with a reduced geographic mismatch is a further advantage that can result in a higher quality of treatment. Even in complex coronary lesions and procedures, rPCI seems to be safe and efficient. The latest developments include telestenting over hundreds of kilometers from a remote platform. Currently, the main limitations are the absence of large-scale randomized trials for the valid assessment of the benefits and disadvantages of rPCI as well as the technical limitations of the currently available rPCI systems.
rPCI is a forward-looking innovation in cardiology that is applicable to a wide range of coronary interventions. Despite the present lack of knowledge and the limited data concerning the outcome for the patient, the available literature reveals promising results that should lead to improvements for physicians and patients.
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Endovascular Solutions for Aortic Arch Diseases: Total and Hybrid
Luca Di Marco, MD, PhD, Giacomo Murana, MD, Gregorio Gliozzi, MD, Davide Pacini, MD, PhD, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy, Luigi Lovato, MD, Francesco Buia, MD, Domenico Attinà, MD, Professor, Division of Radiology, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
1415
Although the endovascular approach is the therapeutic option of choice for thoracic and abdominal aortic diseases, open surgery is still the treatment of choice for aortic arch diseases. While open surgical repair remains the gold standard treatment for complete aortic arch replacement, it continues to be burdened by high mortality and neurologic complications, especially for patients who require redo surgery. Therefore, in the era of endovascular surgery, it is not surprising that hybrid operating rooms, new technologies, and new approaches are strongly challenging open surgery. Less-invasive endovascular procedures, when used to treat aortic arch diseases, when feasible and indicated, have clear advantages over open surgery, primarily because there is no need for cardiopulmonary bypass, hypothermic circulatory arrest, or cerebral protection.
Moreover, patients who have already been treated for acute type A aortic dissection continue to have a considerable risk for future aortic reintervention, which is associated with increased risk for short- and long-term mortality. In light of these advantages, it is clear how selected high-risk patients with aortic arch disease could benefit from the endovascular approach.
However, the hemodynamic and anatomic characteristics of the aortic arch make the endovascular approach in this region challenging. In fact, uncorrected stent-graft placement can have fatal consequences for the patient and increase the risk of endoleaks and stroke. To minimize these potential risks, precise and accurate preoperative planning to achieve optimal stent-graft dimensions and implantation is essential together with careful patient selection. Endovascular options for the treatment of aortic arch disease include both hybrid procedures and total endovascular solutions. This manuscript provides an overview of the current strategies for endovascular aortic arch treatment, including the most recent available series on this topic. In addition, a literature search offers insight into the current state of the art.
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