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Intraoperative evaluation of small-calibre arterial reconstructions
Copyright
ELSEVIER
Ultrasound in Med. & Biol., Vol. 23, No. 3, pp. 473-476, 1997 0 1997 World Federation for Ultrasound in Medicine & Biology F’rinted in the USA. AU rights reserved 0301-5629/97 $17.00 + .I0
PII SO301-5629( 97)00002-l
@Clinical Note INTRAOPERATIVE EVALUATION OF SMALL-CALIBRE ARTERIAL RECONSTRUCTIONS YASUHIKO SUGAWARA, * TOSHIHIKO IKEGAMI, + TOSHIYUKI NAMBA, * HIDEO KIMURA, * KAZUTO INOUE, * KEIICHI KUBOTA, * YASUSHI HARIHARA, * TETSURO MIYATA, * OSAMU SATO, * TADATOSHI TAKAYAMA* and MASATOSHI MAKUUCHI * *Second Department of Surgery, Faculty of Medicine, University of Tokyo, Tokyo, Japan; and + First Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan (Received
4 September
1996; in j&al form
26 November
1996)
Abstract-A new hammerhead-shaped,small probe for intraoperative duplex uhrasound was devised to evaluate small-calibre arterial reconstructions.This probe wasusedin two patients; one with terminal liver cirrhosis who had a left hepatic lobe that had been transplanted from her mother, and a secondpatient with limb-threatening ischaemiawho had undergonearterial reconstructions. The technique wasdfagno& cafly useful and contributed to successfulclinical outcomes. 0 1997World Federation for Ultrasound in Medicine & Biology Key Words: Doppler studies,Intraoperative ultrasound, Arterial reconstruction.
INTRODUCTION Treatment involving small-calibre ( < 3 mm in diameter) vascular anastomoses demands a high degree of technical skill. Hepatic artery thrombosis is the most significant postliver transplantation complication subsequent to hepatic necrosis, biliary leakage and bacteraemia resulting in a high mortality (Lallier et al. 1995). In peripheral vascular surgery, graft failure was found to occur most frequently (23%-43%) within the first 30 postoperative days when the graft was anastomosed to tibioperoneal or paramalleolar arteries. Failures could not be revised when there was no additional adequate distal anastomotic site or autogenous vein graft and primary occlusion ensued (Davidson and Callis 1993; Marks et al. 1992; Pomposelli et al. 1995; Quiiiones-Baldrich et al. 1993). It is important to confirm intraoperatively that vascular anastomoses are secure to prevent such vascular complications. We have devised a new, small, hammerhead-shaped, linear array probe specially designed for intraoperative vascular sonography and have used it in two patients to evaluate its function.
METHODS The concept behind devising this probe was the facility to examine delicate small-calibre vessels and anastomoses. The probe is 18 cm long, hammerheadshaped and weighs 20 g. Its scan surface is 2 mm x 1 cm, with a 7.5MHz linear array, providing a 10.6to &l-MHz B-scan image with a resolution of < 1 mm within a 5- to 40-mm probe focal zone (Fig. 1) . Duplex sonography with this probe was performed using an SSD 2000 (Aloka, Tokyo, Japan). The surgical cavity was filled with warm sterile saline, and the probe was placed adjacent to the arteries and grafts around the anastomotic sites to carefully examine the morphology in B-mode and the arterial flow in Doppler mode. CASE REPORTS Patient 1
On February 21, 1996, an 18-year-old girl with terminal liver cirrhosis due to biliary atresia underwent total hepatectomy and then transplantation of the left liver with the middle hepatic vein from her mother. After reconstruction of the hepatic and portal veins, the left hepatic artery of the recipient (2.5 mm in diam-
Address correspondence to: Yasuhiko Sugawara, M.D., Second Department of Surgery, Faculty of Medicine, University of Tokyo, 7-3-l Hongo, Bunkyo-ku, Tokyo, 113 Japan.
473
Ultrasound in Medicine and Biology
Volume 23, Number 3, 1997
eral forefeet. The ankle pressure indices ( APIs) of the right and left legs were 0.25 and 0.18, respectively. Bilateral femoro-supragenicular popliteal bypasses and infragenicular popliteal-posterior tibia1 bypasses (jumping bypasses) were performed using autogenous vein grafts under tourniquet ischaemia (Shindo et al. 1992). The posterior tibia1 arteries were anastomosed with the grafts with 6-O polypropylene continuous sutures under observation with a magnifying glass. The diameter of the tibial artery anastomosed on the left side was 1.5 mm (at the paramalleolar level) and that on the right side was 2 mm (at the midcalf level). Before anastomosis, ultrasonography of each artery was carried out to determine whether the proposed anastomotic site was appropriate. An artery showing a smooth wall was judged to be appropriate. Each anastomosis, excluding femoral sites, was then scanned ultrasonographically to evaluate the technical adequacy of the anastomosis, which revealed good arterial flow with smooth anastomosal morphology (Fig. 3). This agreed with the completion arteriography results. The grafts were confirmed to be patent by arteriography and duplex ultrasound performed 1 and 8 months after the operation, respectively.
(a)
DISCUSSION
(b) Fig. 1. The newly devised, 7.5MHz linear array probe for vascular duplex sonography. (a) The probe is hammerheadshaped and 18 cm long. (b) The scan surface is 1 cm long.
Colour Doppler ultrasonography with a T-shaped, 7.5-MHz linear array probe has already been used to evaluate blood flow through the graft in living-related liver transplantation (Kasai et al. 1992). However, with this probe, the image is obtained by scanning on
eter) and the left gastric artery of the graft (2.0 mm in diameter) were anastomosed end-to-end with 9-O nylon interrupted sutures by viewing under a microscope (Hashikura et al. 1995; Ikegami et al. 1996). Duplex ultrasonography of the arterial anastomosis showed that the arterial Doppler flow was adequate. In B-mode, the walls at the anastomotic site were shown to be smooth (Fig. 2), which confirmed that the anastomosis was technically appropriate. Liver function became normalised 1 month after the operation. Postoperative
Doppler ultrasound,
which was per-
formed routinely every 2 weeks in the outpatient clinic, demonstrated good arterial flow in the graft for 8 months.
Patient 2 On February 23, 1996, a 75-year-old nondiabetic man presented with rest pain and gangrene in the bilat-
Fig. 2. Intraoperative duplex sonography at the hepatic artery anastomosed end-to-end. The B-mode view revealed a smooth anastomotic morphology, and Doppler scanning revealed a high diastolic flow typical of a low-resistance vessel. G - left gastric artery of the graft; R - left hepatic artery of the recipient.
IOUS for arterial reconstruction 0 Y. SUGAWARAet al.
(a)
ON Fig. 3. Intraoperative duplex sonographyat the posttibial arterial anastomoticsite of the graft (right leg). (a) Before anastomosis, the posttibialartery showinga smoothwall was judged to be an appropriatesite for anastomosis. (b) After anastomosis, the B-modeimageshoweda little “bump” at the anastomosis in the posteriorwall. A schemais shown beneaththe B-mode image.A - posteriortibia1 artery outflow; G - vein graft. The arrow in the schemaindicates the “bump.” The Doppler waveform hashigh systolic and diastolicvelocities. with signalaliasing.
the surface of the liver graft, because the probe head is large and bulky. Therefore, the image only reflects intrahepatic vessel flow indirectly, and the technical adequacy of the vascular anastomoses cannot always be demonstrated. To our knowledge, there are no other reports of the intraoperative use of duplex ultrasound for direct assessment of the vascular anastomosis in liver transplantation. Intraoperative duplex ultrasound is used widely in vascular surgery. It has proved highly valuable for correcting associated technical problems during renal
475
(Dougherty et al. 1993) and carotid (Schwartz et al. 1988) arterial reconstruction. In contrast, for arterial reconstructions of the lower extremities, it was found to be inferior to angioscopy or arteriography for detecting technical problems (Gilbertson et al. 1992). However, it was not the duplex scanning technology itself, but the large sizes of the probe heads, that made it cumbersome to use and resulted in a negative evaluation (Dougherty et al. 1993). Recently, a compact probe, the EntosTM CLlO-5 Intraoperative Vascular Scanhead, was developed independently by ATL (Bothell, WA, USA) for intraoperative use in vascular surgery. Future clinical reports using this probe will reveal its details. As we have never used the ATL probe, a comparison with our probe is not possible. Our limited clinical experience seems to indicate the application of this probe to resolve the previous problems of intraoperative duplex scanning for smallcalibre arterial reconstruction. The small scan size and light weight of our newly developed probe has made safe, simple and direct scanning of delicate vessels and anastomoses possible. The long handle of the probe enabled its potential applications to be widened to include hepatic arterial reconstruction in liver transplantation. More cases must be accumulated in the future to reveal the details of the most suitable indications for, and limitations of, intraoperative vascular sonography using this hammerhead-shaped probe. In summary, a hammerhead-shaped, small probe for intraoperative duplex ultrasound was devised and used in two patients. The technical adequacy of arterial anastomosis was confirmed morphologically and adequate arterial flow was demonstrated intraoperatively, and favourable clinical results were obtained. authorsthank Dr. Toshiyuki Matsunaka, Mr. Tohru Watanabe and Mr. Hide&a Sakai of Aloka Co. Ltd., Tokyo, Japan, for their technical assistance, and Mr. Rokuro Miyazawa of the Department of Medical Photography, University of Tokyo. for his excellent photography of our specimens. Acknowledgements-The
REFERENCES Davidson JT III, Callis JT. Arterial reconstruction of vessels in the foot and ankle. Ann Surg 1993;217:699-710. Dougherty MJ, Hallett JW Jr, Naessens JM, et al. Optimizing technical success of renal revascularization: The impact of intraoperative color-flow duplex ultrasonography. J Vast Surg 1993; 17: 849-857. Gilbertson JJ, Walsh DB, Zwolak RM, et al. A blinded comparison of angiography, angioscopy, and duplex scanning in the intraoperative evaluation of in situ saphenous vein bypass grafts. J Vast Surg 1992;15:121-129. Hashikura Y, Kawasaki S, Okumura N, et al. Prevention of hepatic artery thrombosis in pediatric liver transplantation. Transplantation 1995;60:1109-1112. Ikegami T, Kawasaki S, Matsunami H, et al. Should all hepatic arterial branches be reconstructed in living-related liver transplantation? Surgery 1996: 119:43 l-436.
416
Ultrasound in Medicine and Biology
Kasai H, Makuuchi M, Kawasaki S, et al. Jntraoperative color Doppler ultrasonography for partial-liver transplantation from the living donor in pediatric patients. Transplantation 1992;54:1731-c I I.J. Lallier M, St-Vi1 D, Dubois J, et al. Vascular complications after pediatric liver transplantation. J Pediatr Surg 1995;30:11221126. Marks J, King TA, Baele H, Rubin J, Marmen C. Popliteal-to-distal bypass for limb threatening ischemia. J Vast Surg 1992,15:755760. Pomposelli FB, Marcaccio BJ, Gibbons GW, et al. Dorsalis pedis
Volume 23, Number 3, 1997 arterial bypass: Durable limb salvage for foot ischemia in patients with diabetes melhtus. J Vast Surg 1995;21:375-384. Quitlones-Baldrich WJ, Colburn MD, Ahn SS, Gelabert HA, Moore WS. Very distal bypass for salvage of the severely ischemic extremity. Am J Surg 1993;166:117-123. Schwartz RA, Peterson GJ, Noland KA, Hower JP, Naunheim KS. Intraoperative duplex scanning after carotid artery reconstruction: A valuable tool. J Vast Surg 1988;7:620-624. Shindo S, Tada Y, Sato 0, et al. Esmarch’s bandage technique in distal bypass surgery. J Cardiovasc Surg 1992;33:609-612.
ELSEVIER
Ultrasound in Med. & Biol., Vol. 23, No. 3, pp. 473-476, 1997 0 1997 World Federation for Ultrasound in Medicine & Biology F’rinted in the USA. AU rights reserved 0301-5629/97 $17.00 + .I0
PII SO301-5629( 97)00002-l
@Clinical Note INTRAOPERATIVE EVALUATION OF SMALL-CALIBRE ARTERIAL RECONSTRUCTIONS YASUHIKO SUGAWARA, * TOSHIHIKO IKEGAMI, + TOSHIYUKI NAMBA, * HIDEO KIMURA, * KAZUTO INOUE, * KEIICHI KUBOTA, * YASUSHI HARIHARA, * TETSURO MIYATA, * OSAMU SATO, * TADATOSHI TAKAYAMA* and MASATOSHI MAKUUCHI * *Second Department of Surgery, Faculty of Medicine, University of Tokyo, Tokyo, Japan; and + First Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan (Received
4 September
1996; in j&al form
26 November
1996)
Abstract-A new hammerhead-shaped,small probe for intraoperative duplex uhrasound was devised to evaluate small-calibre arterial reconstructions.This probe wasusedin two patients; one with terminal liver cirrhosis who had a left hepatic lobe that had been transplanted from her mother, and a secondpatient with limb-threatening ischaemiawho had undergonearterial reconstructions. The technique wasdfagno& cafly useful and contributed to successfulclinical outcomes. 0 1997World Federation for Ultrasound in Medicine & Biology Key Words: Doppler studies,Intraoperative ultrasound, Arterial reconstruction.
INTRODUCTION Treatment involving small-calibre ( < 3 mm in diameter) vascular anastomoses demands a high degree of technical skill. Hepatic artery thrombosis is the most significant postliver transplantation complication subsequent to hepatic necrosis, biliary leakage and bacteraemia resulting in a high mortality (Lallier et al. 1995). In peripheral vascular surgery, graft failure was found to occur most frequently (23%-43%) within the first 30 postoperative days when the graft was anastomosed to tibioperoneal or paramalleolar arteries. Failures could not be revised when there was no additional adequate distal anastomotic site or autogenous vein graft and primary occlusion ensued (Davidson and Callis 1993; Marks et al. 1992; Pomposelli et al. 1995; Quiiiones-Baldrich et al. 1993). It is important to confirm intraoperatively that vascular anastomoses are secure to prevent such vascular complications. We have devised a new, small, hammerhead-shaped, linear array probe specially designed for intraoperative vascular sonography and have used it in two patients to evaluate its function.
METHODS The concept behind devising this probe was the facility to examine delicate small-calibre vessels and anastomoses. The probe is 18 cm long, hammerheadshaped and weighs 20 g. Its scan surface is 2 mm x 1 cm, with a 7.5MHz linear array, providing a 10.6to &l-MHz B-scan image with a resolution of < 1 mm within a 5- to 40-mm probe focal zone (Fig. 1) . Duplex sonography with this probe was performed using an SSD 2000 (Aloka, Tokyo, Japan). The surgical cavity was filled with warm sterile saline, and the probe was placed adjacent to the arteries and grafts around the anastomotic sites to carefully examine the morphology in B-mode and the arterial flow in Doppler mode. CASE REPORTS Patient 1
On February 21, 1996, an 18-year-old girl with terminal liver cirrhosis due to biliary atresia underwent total hepatectomy and then transplantation of the left liver with the middle hepatic vein from her mother. After reconstruction of the hepatic and portal veins, the left hepatic artery of the recipient (2.5 mm in diam-
Address correspondence to: Yasuhiko Sugawara, M.D., Second Department of Surgery, Faculty of Medicine, University of Tokyo, 7-3-l Hongo, Bunkyo-ku, Tokyo, 113 Japan.
473
Ultrasound in Medicine and Biology
Volume 23, Number 3, 1997
eral forefeet. The ankle pressure indices ( APIs) of the right and left legs were 0.25 and 0.18, respectively. Bilateral femoro-supragenicular popliteal bypasses and infragenicular popliteal-posterior tibia1 bypasses (jumping bypasses) were performed using autogenous vein grafts under tourniquet ischaemia (Shindo et al. 1992). The posterior tibia1 arteries were anastomosed with the grafts with 6-O polypropylene continuous sutures under observation with a magnifying glass. The diameter of the tibial artery anastomosed on the left side was 1.5 mm (at the paramalleolar level) and that on the right side was 2 mm (at the midcalf level). Before anastomosis, ultrasonography of each artery was carried out to determine whether the proposed anastomotic site was appropriate. An artery showing a smooth wall was judged to be appropriate. Each anastomosis, excluding femoral sites, was then scanned ultrasonographically to evaluate the technical adequacy of the anastomosis, which revealed good arterial flow with smooth anastomosal morphology (Fig. 3). This agreed with the completion arteriography results. The grafts were confirmed to be patent by arteriography and duplex ultrasound performed 1 and 8 months after the operation, respectively.
(a)
DISCUSSION
(b) Fig. 1. The newly devised, 7.5MHz linear array probe for vascular duplex sonography. (a) The probe is hammerheadshaped and 18 cm long. (b) The scan surface is 1 cm long.
Colour Doppler ultrasonography with a T-shaped, 7.5-MHz linear array probe has already been used to evaluate blood flow through the graft in living-related liver transplantation (Kasai et al. 1992). However, with this probe, the image is obtained by scanning on
eter) and the left gastric artery of the graft (2.0 mm in diameter) were anastomosed end-to-end with 9-O nylon interrupted sutures by viewing under a microscope (Hashikura et al. 1995; Ikegami et al. 1996). Duplex ultrasonography of the arterial anastomosis showed that the arterial Doppler flow was adequate. In B-mode, the walls at the anastomotic site were shown to be smooth (Fig. 2), which confirmed that the anastomosis was technically appropriate. Liver function became normalised 1 month after the operation. Postoperative
Doppler ultrasound,
which was per-
formed routinely every 2 weeks in the outpatient clinic, demonstrated good arterial flow in the graft for 8 months.
Patient 2 On February 23, 1996, a 75-year-old nondiabetic man presented with rest pain and gangrene in the bilat-
Fig. 2. Intraoperative duplex sonography at the hepatic artery anastomosed end-to-end. The B-mode view revealed a smooth anastomotic morphology, and Doppler scanning revealed a high diastolic flow typical of a low-resistance vessel. G - left gastric artery of the graft; R - left hepatic artery of the recipient.
IOUS for arterial reconstruction 0 Y. SUGAWARAet al.
(a)
ON Fig. 3. Intraoperative duplex sonographyat the posttibial arterial anastomoticsite of the graft (right leg). (a) Before anastomosis, the posttibialartery showinga smoothwall was judged to be an appropriatesite for anastomosis. (b) After anastomosis, the B-modeimageshoweda little “bump” at the anastomosis in the posteriorwall. A schemais shown beneaththe B-mode image.A - posteriortibia1 artery outflow; G - vein graft. The arrow in the schemaindicates the “bump.” The Doppler waveform hashigh systolic and diastolicvelocities. with signalaliasing.
the surface of the liver graft, because the probe head is large and bulky. Therefore, the image only reflects intrahepatic vessel flow indirectly, and the technical adequacy of the vascular anastomoses cannot always be demonstrated. To our knowledge, there are no other reports of the intraoperative use of duplex ultrasound for direct assessment of the vascular anastomosis in liver transplantation. Intraoperative duplex ultrasound is used widely in vascular surgery. It has proved highly valuable for correcting associated technical problems during renal
475
(Dougherty et al. 1993) and carotid (Schwartz et al. 1988) arterial reconstruction. In contrast, for arterial reconstructions of the lower extremities, it was found to be inferior to angioscopy or arteriography for detecting technical problems (Gilbertson et al. 1992). However, it was not the duplex scanning technology itself, but the large sizes of the probe heads, that made it cumbersome to use and resulted in a negative evaluation (Dougherty et al. 1993). Recently, a compact probe, the EntosTM CLlO-5 Intraoperative Vascular Scanhead, was developed independently by ATL (Bothell, WA, USA) for intraoperative use in vascular surgery. Future clinical reports using this probe will reveal its details. As we have never used the ATL probe, a comparison with our probe is not possible. Our limited clinical experience seems to indicate the application of this probe to resolve the previous problems of intraoperative duplex scanning for smallcalibre arterial reconstruction. The small scan size and light weight of our newly developed probe has made safe, simple and direct scanning of delicate vessels and anastomoses possible. The long handle of the probe enabled its potential applications to be widened to include hepatic arterial reconstruction in liver transplantation. More cases must be accumulated in the future to reveal the details of the most suitable indications for, and limitations of, intraoperative vascular sonography using this hammerhead-shaped probe. In summary, a hammerhead-shaped, small probe for intraoperative duplex ultrasound was devised and used in two patients. The technical adequacy of arterial anastomosis was confirmed morphologically and adequate arterial flow was demonstrated intraoperatively, and favourable clinical results were obtained. authorsthank Dr. Toshiyuki Matsunaka, Mr. Tohru Watanabe and Mr. Hide&a Sakai of Aloka Co. Ltd., Tokyo, Japan, for their technical assistance, and Mr. Rokuro Miyazawa of the Department of Medical Photography, University of Tokyo. for his excellent photography of our specimens. Acknowledgements-The
REFERENCES Davidson JT III, Callis JT. Arterial reconstruction of vessels in the foot and ankle. Ann Surg 1993;217:699-710. Dougherty MJ, Hallett JW Jr, Naessens JM, et al. Optimizing technical success of renal revascularization: The impact of intraoperative color-flow duplex ultrasonography. J Vast Surg 1993; 17: 849-857. Gilbertson JJ, Walsh DB, Zwolak RM, et al. A blinded comparison of angiography, angioscopy, and duplex scanning in the intraoperative evaluation of in situ saphenous vein bypass grafts. J Vast Surg 1992;15:121-129. Hashikura Y, Kawasaki S, Okumura N, et al. Prevention of hepatic artery thrombosis in pediatric liver transplantation. Transplantation 1995;60:1109-1112. Ikegami T, Kawasaki S, Matsunami H, et al. Should all hepatic arterial branches be reconstructed in living-related liver transplantation? Surgery 1996: 119:43 l-436.
416
Ultrasound in Medicine and Biology
Kasai H, Makuuchi M, Kawasaki S, et al. Jntraoperative color Doppler ultrasonography for partial-liver transplantation from the living donor in pediatric patients. Transplantation 1992;54:1731-c I I.J. Lallier M, St-Vi1 D, Dubois J, et al. Vascular complications after pediatric liver transplantation. J Pediatr Surg 1995;30:11221126. Marks J, King TA, Baele H, Rubin J, Marmen C. Popliteal-to-distal bypass for limb threatening ischemia. J Vast Surg 1992,15:755760. Pomposelli FB, Marcaccio BJ, Gibbons GW, et al. Dorsalis pedis
Volume 23, Number 3, 1997 arterial bypass: Durable limb salvage for foot ischemia in patients with diabetes melhtus. J Vast Surg 1995;21:375-384. Quitlones-Baldrich WJ, Colburn MD, Ahn SS, Gelabert HA, Moore WS. Very distal bypass for salvage of the severely ischemic extremity. Am J Surg 1993;166:117-123. Schwartz RA, Peterson GJ, Noland KA, Hower JP, Naunheim KS. Intraoperative duplex scanning after carotid artery reconstruction: A valuable tool. J Vast Surg 1988;7:620-624. Shindo S, Tada Y, Sato 0, et al. Esmarch’s bandage technique in distal bypass surgery. J Cardiovasc Surg 1992;33:609-612.