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!