the minimal invasive surgery on aorta disease

In the past , surgery on aorta disease remains to be one of the major procedures in the realm of vascular surgery . The mortality and morbidity remains to be the major concern of those patients suffered from the disease. Thanks to the advance of the medical technology, nowadays we are able to treat lots of aorta dissease in a less invasive fashion. The invention of arotic stentgrafting (endovascualr treatment; EVAR or TEVAR) makes the procedure more safe and less painful for the patients.
Finally, the stentgraft are available in Taiwan sinced 2005. And in our hospital, we vascular surgeons soon adopted the new technique to treat our patients. We can now treat a giant thoracic aneurysm or abdominal aneurysm through tiny holes in the patients groin area!
more information about our institution for those who live abroad: internatinal service center of CGMH

Tip on creating dialysis graft venous anastomosis

A tip about doing the venous anastomosis of a dialysis graft.

When doing the dialysis graft creation, venous anastomosis is one of the important parts of the procedure. A smooth and wide open venous anastomosis is the important to the long term patency of the graft.
Usually, the target vein would became smaller than its original size because of vessel spasm due to the extensive dissection of surrounding tissue and manipulation of the vessel. Small target vessel lumen would add difficulties to the anastomosis. Here is a technique which can made the anastomosis easier.

I usually use a 19 gauge intravenous injection catheter as a simple tool to dilate the target vessel. The IC catheter is inserted into the lumen of the target vein after proximal and distal clamping of the vein. From the IC catheter, normal saline is gently injected. The target vein is thus dilated to a bigger size under the pressure. Then, from the tiny injection hole, I can make a longitudinal incision for following anastomosis.
The graft end will be sutured easily to the dilated target vein. Thus a wider anastomosis can be created.

Treatment of dialysis graft outlet stricture: patch angioplasty

Dialysis graft outelt stricture is one of the most frequent complication/situation that a dialysis surgeon faces in his dailiy practice. To cope with the stenotic lesion, the oldest way, probably the most reliable, is to do surgical revision.
There are two ways of surgical revision of the graft outlet. Here shows the so called" patch angioplasty" method. If the stenotic lesion is a focal or short lesion, we can just longitudinally incise teh graft outlet, and apply a ePTFE patch (which is the same material of the graft) to augment the outelt space. after the operation, the graft outlet should be widely open.
The operation usually takes around 1 hour to perform. ofcourse, reoperation sometimes will be troublesome. However, most of the stenotic lesion can be fixed by patch angioplasty. Only if the lesion is too long, then we will try to fix the lesion using a jump graft.

Ofcourse nowadays most of the graft outelt stenotic lesion are first treated with angioplasty balloons/ stenting, which is less invasive. However, surgeon should always keep himself familiar with the open procedure. and once the PTA doesnt work, we still can provide a feasible choice of treatment instead of giving up the graft!

difficult dialysis access creation- chest loop

This is a dialysis patient with exhausted bilateral arm's venous property. Due to the need of long term dialysis, I have created a anterior chest loop graft for her some 6 years ago. And fortunately, the anterior chest dialysis graft lasted functional for over 6 years. Several weeks ago, because of the degenration of the graft, low flow with frequent thrombosis was noted.
My stratagy is : insert a cuffed tunneled catheter via the right internal jugular vein for dialysis and perform a anterior chest dialysis graft redo procedure. I have implanted a new graft and do the anastomosis of either end of the graft to the original graft inlet and outelt stumps.

I think, with meticulous work and proper clinical judgment, we still can perform dialysis graft for long term usage on those patients whose bilateral arm are not suitable for graft creation. The anterior chest loop graft is one of the form which can/should be considered.

Method to treat dialysis graft outelt stricture

Outlet stricture is the most common problem of dialysis graft. If not treated properly, it may lead to dialysis graft thrombosis. How can we deal with dialysis graft outlet stenosis?
Traditionally, surgeons can do an venous outlet revision, either by patch angioplasty or jump graft revision, to address the problem of graft outlet stricture. its a rather staightforward way to treat the lesion. However, surgical revision needs surgical exploration of the vessel and is more invasive and time consuming. (compare to recently endovascular method)
Nowadays we can treat the lesions using P.T.A.. That is to say, we may dilate the stricture using angioplasty balloon percutaneously. However, rocoil or recurrence of the stenosis may need repeated procedures.
And if the lesion is refractory to angioplasty alone or it recured early, we may put in stents to prevent the recoil of the lesion. In my experience, we should put in covered stents in stead of bare metal stents to treat the dialsis graft outelt lesions. Because it seems that the bare stents do have the problem of in-stent stenosis in short time.

The picture showes here depict a typical graft outlet lesion, which is refractory to P.T.A, successfully treated using a covered stent uneventfully(Fluency, Bard)

P.T.A.

P.T.A. stands for "percutaneous transluminal angioplasty". It is a less invasive percedure , compared to the traditional surgical revision, to treat vessel stenosis or occlusion.
"Percutaneous" means that the procedure is start with sticking a needle into the target vessel through the skin in stead of cutting a big wound to exposure the vessel. Once the access to the vessel was created, a working sheath was inserted into the vessel, just like doing a "i.v." injection, to secure the access. We can then insert some kind of catheter, guidewire and balloons via the sheath to attack the lesions (stenosis or occlusion).
"transluminal angioplasty" means that the procedure is comprised of dilatation of the stenotic vessel segments (angioplasty) using angioplasty balloons instead of repair the lesions using traditional "cut and sew" methods.
In short, when doing P.T.A. , we insert a balloon over a guidewire into the vessel percutaneously and send the balloon right to the target lesion (where the vessel is stenotic). And then we inflat the balloon to dilate the vessel upto the diameter we disire to increase the blood flow. At the endo of the procedure, we take out the catheters and balloons. Through P.T.A we can treat vessels with only with punture wounds and we don't have to cut the vessels anymore.

We can apply this kind of P.T.A technique to treat the vessel problems , including arteries and veins, all over our body.

What is Port A implantation

"Port A" is a device implanted subcutaneously used for long term intravenous injection. The term is derived from the product name "Port-a-cath", which is one of the oldest device. however, there are several deffrent types of similar devices on the market made by different company nowadays.

The subcutaneous implantable infusion system consists of a catheter and a injection port. The port is implanted subcutanously, usually on the infraclavicular area, and can be punctured repeatly several hundred times. The catheter connected to the port was implanted into the venous system all the way to the central vein. The catheter tip was usually placed in SVC or right atrium. Thus the intravenous injection substance (such as drug for chemotherapy) will goes directly to the central vein through the catheter.

In short, it's a deviced implanted in the human body used for long-term and repeated injection of intravenous drug. Usually, it is implanted by vascular surgeon in the operation room via the right cephalic vein or internal jugular vein.

log of the day

1 Port A implantation
1 permanent dialysis catheter implantation
1 dialysis graft implantation
3 PTA of dialysis graft

the sequence of treatment for DM foot

I received a call today from our plastic surgeon. One of his inpatients was diagnosed to be a DM foot with foot ulcers. He had perated on the foot for several times to debride the necrotic tissue. According to his statement, the perfusion of those tissue were not so good. And the condition of the soft tissue got worsen after each debridement. He thus than arranged noninvasive study and image study which revealed that there is a total occlusion over the patient's femoral artery! No wonder that the lesion did not get better after debridement!
He had then call me for the possibility of revascularization.

Sure, revasclarization is a must for the tissue perfussion which is the fundamental element of wound healing. The problem is , the sequence (or priority) of treatment was obviously wrong!

From the viewpoint of a vascular surgeon, we should do as follows for a DM foot with ischemic compoment.

1. Infection control or minor debridment of the infected tissue
2. Revascularization , either PTA or bypass
3. Debridement or amputation to facilitate wound healing
4. Reconstruction, if needed

It's a pity that our physicion, let alone those patient, nearly always think about the vascular condition to late. They did not pay attention to their vascular condition. They may miss the chance of the optimal treatment.

My point is, vascular condition is the most fundamental. We have to keep in mind the diagnosis of ischemic leg.

Treatment of dialysis graft outlet stricture: covered-stent

History
A patietn of ESRD on regular dialysis vie her left upper arm graft. graft outlet segmental stricture was noted and the stenosis was refratory to repeated PTA (percutaneous balloon angioplasty).
Operative finding
During the venography study, graft outelt segmental stricture was noted. Due to the elasticity of the stricture, definite treatment is needed.
Strategy
Definite repair of the outlet stricture was needed. The options were:
1. Surgical revision, which is more invasive and time consuming. In addition, the lesion extended up to the high axillary vein make the revision more difficult. General anesthesia was needed to do the jump graft revision which will add on more anesthesia risk.
2. PTA with stent insertion. Covered-stent insertion over the stricture segment can prohibit immediate recoil and may prevent recurrent stricture in the long run. In addition, it's only a percutaneous procedure which is low risk to the patient. Thus we had proceed with covered-stent implantation to deal with the graft outlet recurrent stricture.

popliteal total occlusion: bypass with Distaflo!

History
A patient of chronic ischemic leg presented with right side gangrene toes. Image study showed right side popliteal artery total occlusion. Revascularization was thus indicated.
Op finding
The right side above knoww popliteal artery was explored to be severe calcified and severe diseased. Endarterectomy was done. The below knee popliteal artery was then explored.
Operation Strategy
PTA alone was note considered because of longer patency was expected. Due to the location of the total occlusion(just behind the knee joing), PTA with stentgrafting was not considered. A Distaflo (cuffed ePTFE graft was implanted as a bypass graft. You can see the cuff of the graft was nicely seated on the target vessel.

Conference List

Vascular Surgery is a clinical science keep on changing. A clinician has to keep up to date in order to provide the most appropriate treatment options.
Take part in academic conferences/symposium is a must for surgeons/physicians in medical center. It's our obligation to catch the state-of-the-art knowledge. By attending those related conferences/symposiums, surgeons may learn new knowledge, techniques, products to aid in their clinical practice.
I have here listed some major conferences/symposiums related to vascular surgery which other surgeons may be interested in participating in the forthcoming year .
Here is the Conferece List.

The list will be updated on regular basis and suggestions are welcome.

case: FP bypass using Distaflo graft

Today, a patient of PAOD (peripheral artery occlusive disease) who was discharged from the hospital some 10 days ago came back to the clinic for his posoperative check. Here is his postoperative images.
History
He was a victim of right femoral artery total occlusion presented with severe intermittent claudiction. a right side femoro-popliteal bypass had been performed in some other hospital around half a year ago. unfortunately, the graft failed almost immediately after the procedure and the symptom had never been treated. (Here you can see the previous inserted graft, which is occluded already) He thus then came to my institution for further help.
Operative finding
severe atheromatous change of CFA, right side was noted during the procedure. I have used a ePTFE graft which has a cuffed design (Distaflo, BARD) for the bypass graft. the target vessel was the below knee popliteal artery. The postoperative image showed here a patent graft with beautiful distal anastomosis. The cuffed shape of the arterial anastomosis had been showed clearly and beautifully. The flared cuff design of the graft, compare to the regular graft, can enhance the artery blood flow and decrease the possible turbulance blood flow over the anastomosis thus in turn decrease the future intimal hyperplasia on the vessel wall. Theoretically, it can prolong the distal bypass graft patency.

The patient had been rather well after the surgery. No more claudication was complained.
I sure hope that the cuffed design of the graft can minimize the possible stenosis in the future!

vascular surgery in Taiwan

I am a vascular surgeon in Taiwan. In our center, there are three sections in Department of Thoracic & Cardiovascular Surgery: section of cardiac surgery, section of thoracic surgery and section of vascular surgery. Actually, my hospital is on of the few hospitals in Taiwan that has set up an independent section of vascular surgery. There is no department of vascular surgery in most of the hospitals in Taiwan.
In the past , there were no vascular surgeons in Taiwan. Most of the vascular procedures here in Taiwan are performed by cardiac surgeons, especially in those hospitals which does not set up an Vascular Section. Arterial bypass, venous procedures and dialysis access creation procedures had long time been a part of the training program for those cardiac surgeons. In recent years, more and more surgeons, had devoted themselves totally to the field of vascular surgery, although they had been trained as a cardiac surgeon as well.
I had been trained as a thoracic & cardiovascular surgeon. After I was promoted as an independent surgeon, I choose to be a vascular surgeon doing only vascular and endovascular works. Taiwan Society for Vascular Surgery was set up in 2005 as the first and only society devoted to vascular surgery in Taiwan. I believe that the number and the quality of vascular/endovascular procedures here will gain a big leap in the nearest future.

case: Port A (subcutaneous implanted injection port)

left subclavian vein and innominate vein occlusion

occlusion in SVC

Lesion was crossed by guidewire first, followed by the insertion of Port A catheter
History:
A case of breast cancer with lung metastasis. She had received left side MRM for her breast cancer several years ago. She had alse received a left side Port A insertion in the past for chemotherapy ( which was removed later ). This time she was arrange for a new Port A in order to receive further chemotherapy to cope with the metastatic cancer.
Operative finding and stragegy:
I had attempt to insert the central line via the left side cephalic vein, but failed for some how. On table angiography then showed the left side subclavian vein and innominate vein total occlusion! Thus I have to give up the left side approach. I have tried the right side internal jugular vein for another access to insert the Port A cather. However, the guide wire cannot be put through to the right atrium under the fluroscopic guide. An on table venography was then perform to demostrate any obstruction of the vessel. a filling defect over the SVC was discovered. I have managed to use the Terumo wire to cross the lesion cautiously and then insert the Port A catheter through a peel-away sheath following the guidewire. The injection Port had been placed in the usual site (infraclavicular area).
This was a good example of using on table venography to aid the insertion of a Port A catheter on a difficult case which had a central vein problem.

case: dialysis graft thrombectomy + outlet patch revision

left upper arm dialysis graft occlusion

severe intimal hyperplasia caused stricture of vessel lumen

Patch angioplasty to augment the lumen


History:
A patient of ESRD on regular dialysis. Acute thrombosis of her left upper arm graft was noted 3 days ago and emergent thrombectomy was performed. Unfortunately, recurrent thrombosis was noted right after the surgery. She was scheduled for recannalization of the graft.
Operative finding:
The patient's left upper arm dialysis ePTFE graft was total thrombosed. The graft outelt was explored directly and severe intimal hyperplaia of the graft-venous junction was noted. Apparently, the hyperplasia had lead into severe stenosis of the outflow tract thus in turn caused the graft repeated thrombosis.
My operative strategy:
In addition to the thrombectomy of the graft using Fogarty thrombectomy catheter, I had to treat the graft outlet stenosis as well to keep the graft open. Due to the focal stricture which was less than 2 centimeter in length, I have decided to put a ePTFE patch on the outflow tract to augment the size of the vessel.
After the procedure, the thrill on the graft was rather easy and vivid to palpate. She was sent to the dialysis room after the procedure and receive the dialysis treatment via the graft.

case: dialysis graft thrombectomy + outlet jump graft revision

dialysis graft outlet stricture

jump graft revision of the outlet

History:
A patient of ESRD on regular dialysis. The dialysis graft is on his left upper arm. He had received dialysis graft outlet patch revision some one month ago. Repeated graft thrombosus had brought him to surgery.
Operation finding:
Left upper arm brachial-axillary graft total thrombosis with the graft outlet severe stenosis.
Operation stratagy:
In addition to the thrombectomy of the graft, underlying stricture of the vessel must be addressed in order to keep a good operation result.(as the DOQI guideline said) Thus I attacked the dialysis graft outlet stenosis directly and explored the more proximal axillary vein. Once I have found the suitable new venous outlet, I put in a segment of ePTFE jump graft for a bypass.( in this case, a cuffed graft) The bypass graft had created a smooth and wide open graft outlet and thus prevent further thrombosis episode hopefully.
The thrill of the dialysis was fair after the procedure. And the patient had been put on dialysis via the original graft immediately after the operation.

Start to blog in English

As a vascular surgeon, also a computer user who is addicted to the internet, I have been blogging in Chinese (Mandarin) for over one year. I have enjoyed the interactions between my readers and me very much. Now I want to start to blog in English, so as to open a window to someone who cannot read Chinese.
If you are interested in a surgeon’s life in his clinical practice, here is the place to visit. I work in a rather large medical center in Northern Taiwan and lead a busy life. In addition to caring of my inpatients and doing lots of clinical research works, I spend 3 whole days a week in the operation room, doing surgeries on aorta, peripheral arteries, dialysis access…etc. The life of surgeons here in Taiwan is really different from those in the western world. But the commitment of physicians to give the patients the best treatment is never different all over the world.
Please come back frequently and enjoy my images and story.
Comments are welcome!