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Background: In pancreatic cancer, extensive tumor involvement of the mesenteric venous system poses formidable challenges to operative resection. Such involvement can result from cavernous collateral veins leading to increased intraoperative blood loss or long-segment vascular defects of not only just the superior mesenteric vein but also even jejunal/ileal branches. Strategies to facilitate margin-free resection and safe vascular reconstruction in pancreatic surgery are important, particularly because systemic control of the tumor is improving with multi-agent chemotherapy regimens., Methods: We describe a systematic, multidisciplinary assessment for patients with pancreatic cancer that involves the superior mesenteric vein, as well as the preoperative planning of those undergoing operative resection. In addition, detailed descriptions of operative approaches and technical strategies, which evolved with increasing experience at a high-volume center, are presented., Results: For the preoperative evaluation of tumor-free, vascular locations for potential reconstruction and collateralization, computed tomographic imaging with high-resolution of vascular structures (used with 3-dimensional or cinematic rendering) allows a precise calibration of radiographic data with intraoperative findings. From an operative perspective, we identified 5 potential strategies to consider for resection: collateral preservation, mesoportal bypass (preresection), mesoportal interposition graft (postresection), mesocaval shunt, and various combinations of these strategies. Many of these techniques use interposition grafts, making it essential to assess autologous veins (preferred conduit for reconstruction) or to prepare cryopreserved vascular allografts (an alternative conduit, which must be thawed and should be matched for size and blood type)., Conclusion: Herein we share operative strategies to overcome involvement of the superior mesenteric vein in pancreatic cancer. Improvements in preoperative planning and operative technique can address common barriers to resection with curative intent., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to develop a reduced profile stainless steel Greenfield filter with an over-the-wire delivery system and to compare its performance with the existing Food and Drug Administration-approved Greenfield filters. In addition, we wanted to standardize a system for evaluating filter prototypes., Methods: Percutaneous stainless steel filters with various hook configurations were evaluated for efficacy and safety in four in vitro modules designed to reproduce potential liabilities experimentally. Animal studies to assess thrombus capture and resolution, filter stability, migration, and hemodynamics were completed in 4 dogs and 38 sheep., Results: Mathematical modeling suggested that hook angle was the most relevant factor in improving resistance to migration. Prototypes that varied with respect to hook length and angle were evaluated in both the in vitro testing unit and in sheep. The stainless steel filter with two downward directed hooks provided clot capture comparable with the current Greenfield filter, maintenance of flow, and resistance to fatigue and corrosion while providing significant resistance to migration and penetration (p < 0.05)., Conclusions: The percutaneous stainless steel Greenfield filter with the alternating hook design provides a reduced profile device that can be placed over a wire to improve positioning. The use of a standardized testing system reduced both the time and cost of bringing this new device to the market.

A modification of the technique of liver transplantation by the face-à-face venacavaplasty is described and the use in four patients reported. This technique enables livers with a small vena cava to be inserted in an anatomic fashion and should help increase the use of such grafts where disparity between vessel size exists.

Nineteen major anomalies of the vena cava or its branches were encountered in patients requiring abdominal vascular surgery and related procedures at Barnes Hospital during the past 5 years. The classification of these anomalies, their embryologic development, associated variants, and surgical considerations are discussed. Careful review of preoperative computed tomographic scans and familiarity with these anatomic variants may allow the surgeon effectively to avoid potentially disastrous intraoperative consequences.

The Budd-Chiari syndrome (BCS) is caused by hepatic venous outflow obstruction, which often leads to death as a result of portal hypertension and liver failure. Therapeutic approaches vary widely from conventional medical therapy to liver transplantation. If and when a patient suffering with BCS needs surgery remains a matter of contention. However, it is well accepted that portacaval shunt surgery and orthotopic liver transplantation represent efficient surgical treatments of this condition. We report on a patient with an eventful course after BCS was diagnosed. After portacaval shunt surgery the patient had acute liver failure and had a successful orthotopic liver transplantation.

Because of the rarity of child donors, in cases of adult donors room requirement for the liver graft is a major technical obstacle to liver transplantation in children. To overcome this difficulty in a child, the authors performed an orthotopic transplantation with an adult liver that had been reduced to the left lobe. The absence of technically-related complications suggests that this procedure might facilitate the performance of liver transplantation in children.

Variations in the anatomy of the inferior vena cava are important in abdominal surgery. A patient with recurrent bleeding from esophageal varices was noted to have a single left inferior vena cava at the time of panangiography. An interposition mesocaval H shunt subsequently was performed successfully. This represents the first reported case in which a mesocaval H shunt has been performed in a patient with a single left inferior vena cava.

A unique case is discussed in which a Greenfield filter failed structurally after less than 1 year in situ. In the absence of external trauma, two struts of the filter separated from the hub and migrated into the retroperitoneal tissues. A brief discussion of the complications of Greenfield filters concludes with a possible explanation of this particular problem.