We thank doctors Zhou Feng, Ma Tiantian, and Zhu Dongming at our hospital for providing the assistance with ultrasound examination.

The MNTT was conducted according to the human research protocol approved by the ethics committee of the Affiliated Suzhou Science &#38; Technology Town Hospital of Nanjing Medical University (IRB2021029).
1. Preoperative evaluation
<ol>
	<li>Check the medical history: Ensure that the patients have no coagulation abnormalities, valvular heart disease, congestive heart failure, peripheral vascular disease, skin disease, history of central venous catheterization, history of pacemaker implantation, neck and chest trauma, or surgical diseases.</li>
	<li>Perform physical examination results: Ensure symmetrical blood pressure in both upper limbs, good arterial pulse, strong pulsation, negative Allen test11, good venous distensibility after binding the tourniquet, no edema or varicose veins in the upper limb, and no previous central or peripheral venous scars.</li>
	<li>Perform comprehensive assessment of the forearm vasculature of the patient&#39;s operative limb by color Doppler ultrasound.</li>
</ol>
2. Disinfection and anesthesia
<ol>
	<li>Place the patient in the supine position with external rotation and abduction of the operative upper limb.</li>
	<li>Perform routine iodophor disinfection, draping, and local infiltration anesthesia with 1% lidocaine.</li>
</ol>
3. Superficial fascia exposure
<ol>
	<li>Make a 4-cm skin incision (longitudinal incision) at a distance of &#60;2 cm between the radial artery and the cephalic vein of the forearm, and ensure it is relatively close to the cephalic vein.</li>
	<li>Separate the subcutaneous adipose tissue using curved hemostatic forceps to expose the superficial fascia. Look for the presence of the cephalic vein and its surrounding tissues below the superficial fascia (Figure 2a). Do not open the superficial fascia in this step and do not use the electric knife to stop the bleeding.</li>
</ol>
4. Preparation of the cephalic vein
<ol>
	<li>Ensure that below the exposed superficial fascia, the cephalic vein (including part of the vasa vasorum) and its surrounding adipose tissue could be clearly seen.Make two tunnels along the direction perpendicular to the cephalic vein. The tunnel openings should be located &#62;1 cm from both sides of the cephalic vein.</li>
	<li>Pull the cephalic vein close to the radial artery by two blue vessel loops passing through the tunnels at each end to facilitate surgical suturing (Figure 2b).</li>
</ol>
5. Preparation of the radial artery
<ol>
	<li>Cut the tissue layer by layer to expose the radial artery pedicle (including the radial artery and its accompanying veins on both sides) in the pulsating area of the radial artery that can be reached with the index finger. Ligate the small artery branches and pick out the radial artery pedicle with the hemostatic forceps. Dissect the radial artery pedicle for about 40-50 mm.</li>
	<li>Pass the two red vessel loops through each end of the radial artery pedicle. The radial artery could be pulled to be closer to the cephalic vein to facilitate the surgical suture (Figure 2c).</li>
</ol>
6. Opening the cephalic vein and the radial artery
<ol>
	<li>Place a vascular clamp along the tunnel at both ends of the cephalic vein to block the cephalic vein blood flow. Place a vascular clamp at each end of the pedicle to block arterial blood flow. 
	NOTE: Although vascular clamps were used to block blood flow, the intact tissue is preserved around the cephalic vein, which plays a better protective role for the vessels.</li>
	<li>Pull the red vessel loops to bring the radial artery pedicle closer to the cephalic vein, and an incision is made on the lateral wall corresponding to the radial artery and cephalic vein.</li>
	<li>Lift the superficial fascia at the cephalic vein gently with micro-forceps and cut the superficial fascia and the wall of the cephalic vein with a micro-scissor or sharp knife. The incision length should be about 8-10 mm. 
	NOTE: Do not touch or mobilize the vein outside this incision.</li>
	<li>Open the arterial sheath and the wall of the radial artery successively to make an 8-10-mm-long incision with a sharp knife and microscopic scissors, taking care not to twist the vessel. The incision is in the lateral wall of the artery. 
	NOTE: Do not touch or mobilize the artery outside this incision.</li>
	<li>Gently rinse the cephalic vein and radial artery with heparin saline solution (25 IU/mL) to remove any blood or blood clots.</li>
</ol>
7. Functional end-to-side anastomosis
<ol>
	<li>Use the 7.0 non-absorbable single-strand suture to establish vein-arterial anastomosis (side-to-side) with the Kunlin&#39;s technique (Figure 2d, e). Suture the posterior wall of the vessel first, and then suture the anterior wall of the vessel. Pull the vessels close to each other to reduce vascular tension.</li>
	<li>Open the blood flow and ligate the distal cephalic vein to form a functional end-to-side anastomosis (Figure 2f).</li>
	<li>Ensure that no obvious bleeding is detected in the surgical field and use a mattress suture for surgical incision.</li>
</ol>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/62784/62784fig02.jpg" /> 
Figure 2. Surgical steps of the modified no-touch technique. a: Exposure of the cephalic vein with the surrounding tissue in situ. b: Placing the blue vessel loop. c: Exposure of the radial artery and its companion vein. d: A side-to-side anastomosis using the Kunlin&#39;s technique. e: Anastomosed the posterior wall of the vessel. f: The distal cephalic vein was ligated to form a functional end-to-side anastomosis. <a href="https://www.jove.com/files/ftp_upload/62784/62784fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

<ol>
	<li>Trerotola, S. O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=KDOQI+clinical+practice+guideline+for+vascular+access+2019+update:+Kinder,+Gentler,+and+More+Important+Than+Ever.">KDOQI clinical practice guideline for vascular access 2019 update: Kinder, Gentler, and More Important Than Ever.</a> Journal of Vascular and Interventional Radiology. 31 (7), 1156-1157 (2020).</li><li>Schmidli, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Editor's+Choice+-+vascular+access:+2018+clinical+practice+guidelines+of+the+European+Society+for+Vascular+Surgery+(ESVS).">Editor's Choice - vascular access: 2018 clinical practice guidelines of the European Society for Vascular Surgery (ESVS).</a> European Journal of Vascular and Endovascular Surgery. 55 (6), 757-818 (2018).</li><li>Abreo, K., Buffington, M., Sachdeva, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Angioplasty+to+promote+arteriovenous+fistula+maturation+and+maintenance.">Angioplasty to promote arteriovenous fistula maturation and maintenance.</a> Journal of Vascular Access. 19 (4), 337-340 (2018).</li><li>Souza, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+no-touch+preparation+technique:+Technical+notes.">A new no-touch preparation technique: Technical notes.</a> Scandinavian Journal of Thoracic and Cardiovascular Surgery. 30 (1), 41-44 (1996).</li><li>Souza, D. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=High+early+patency+of+saphenous+vein+graft+for+coronary+artery+bypass+harvested+with+surrounding+tissue.">High early patency of saphenous vein graft for coronary artery bypass harvested with surrounding tissue.</a> Annals of Thoracic Surgery. 71 (3), 797-800 (2001).</li><li>Souza, D. S., Gomes, W. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+future+of+saphenous+vein+graft+for+coronary+artery.">The future of saphenous vein graft for coronary artery.</a> Revista Brasileira de Cirurgia Cardiovascular. 23 (3), (2008).</li><li>Souza, D. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Harvesting+the+saphenous+vein+with+surrounding+tissue+for+CABG+provides+long-term+graft+patency+comparable+to+the+left+internal+thoracic+artery:+results+of+a+randomized+longitudinal+trial.">Harvesting the saphenous vein with surrounding tissue for CABG provides long-term graft patency comparable to the left internal thoracic artery: results of a randomized longitudinal trial.</a> Journal of Thoracic and Cardiovascular Surgery. 132 (2), 373-378 (2006).</li><li>H&#246;rer, T. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=No-touch+technique+for+radiocephalic+arteriovenous+fistula:+surgical+technique+and+preliminary+results.">No-touch technique for radiocephalic arteriovenous fistula: surgical technique and preliminary results.</a> Journal of Vascular Access. 17 (1), 6-12 (2016).</li><li>Sadaghianloo, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Radial+artery+deviation+and+reimplantation+inhibits+venous+juxta-anastomotic+stenosis+and+increases+primary+patency+of+radial-cephalic+fistulas+for+hemodialysis.">Radial artery deviation and reimplantation inhibits venous juxta-anastomotic stenosis and increases primary patency of radial-cephalic fistulas for hemodialysis.</a> Journal of Vascular Surgery. 64 (3), 698-706 (2016).</li><li>Xiaohe, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+modified+no-touch+technique+for+anastomosis+to+create+a+radiocephalic+arteriovenous+fistula.">A modified no-touch technique for anastomosis to create a radiocephalic arteriovenous fistula.</a> Journal of Vascular Surgery Cases, Innovations and Techniques. 7 (4), 686-690 (2021).</li><li>Lok, C. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=KDOQI+Clinical+Practice+Guideline+for+Vascular+Access:+2019+Update.">KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update.</a> American Journal of Kidney Diseases. 75 (4), 1 (2020).</li><li>Xiaohe, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+report+of+4+cases+of+autogenous+forearm+arteriovenous+fistula+constructed+by+modified+no-touch+technique.">Clinical report of 4 cases of autogenous forearm arteriovenous fistula constructed by modified no-touch technique.</a> Chinese Journal of Blood Purification. 10 (20), 693-695 (2021).</li><li>Allon, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Association+of+preexisting+arterial+intimal+hyperplasia+with+arteriovenous+fistula+outcomes.">Association of preexisting arterial intimal hyperplasia with arteriovenous fistula outcomes.</a> Clinical Journal of the American Society of Nephrology. 13 (9), 1358-1363 (2018).</li><li>Allon, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Vascular+calcification,+intimal+hyperplasia,+and+arteriovenous+fistula+maturation.">Vascular calcification, intimal hyperplasia, and arteriovenous fistula maturation.</a> American Journal of Kidney Diseases. 58 (3), 437-443 (2011).</li><li>Vazquez-Padron, R. I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=intimal+hyperplasia+and+arteriovenous+fistula+failure:+looking+beyond+size+differences.">intimal hyperplasia and arteriovenous fistula failure: looking beyond size differences.</a> Kidney360. 2 (8), 1360-1372 (2021).</li><li>Shenoy, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+technique+determines+the+outcome+of+the+Brescia/Cimino+AVF.">Surgical technique determines the outcome of the Brescia/Cimino AVF.</a> Journal of Vascular Access. 18, 1-4 (2017).</li><li>Bai, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Artery+to+vein+configuration+of+arteriovenous+fistula+improves+hemodynamics+to+increase+maturation+and+patency.">Artery to vein configuration of arteriovenous fistula improves hemodynamics to increase maturation and patency.</a> Science Translational Medicine. 12 (557), (2020).</li></ol>

Venous juxta-anastomotic stenosis is one of the main factors affecting the maturation of AVF5. It is known to be closely related to intimal hyperplasia13,14,15. However, prevention strategies for intimal hyperplasia are still limited. Modified surgical procedures16 such as RADAR have been shown to have less venous juxta-anastomotic stenosis, increased maturation and patency, and fe...

Radio-cephalic autologous arteriovenous fistula (RC-AVF) have been regarded as the primary and best choice for vascular access in hemodialysis patients1,2. However, the early failure to mature continues to be a major problem with RC-AVF creation3. Different surgical methods have different degrees of vascular injury and affect the maturation of RC-AVF. In 1996, Souza4 first proposed the use of a no-touch technique (NTT) to separate the great saphenous vein in coronary artery bypass grafting and achieved good results5,6,7. Horer et al.8 was the first to use NTT to construct RC-AVF. At the 1-year follow-up, primary patency was 54% and secondary patency was 80%. Sadaghianloo et al.9 further extended the concept of no-touch technology and proposed the radial artery deviation and reimplantation (RADAR) technique. This technique is associated with less juxta-anastomotic stenosis. However, the inflow artery stenosis was more prominent with RADAR. We speculate that this may be related to the severance of the radial artery and skeletonization of the distal tip of the artery.
To further reduce the injury to veins and arteries during the operation, we proposed a new modified no-touch technique (MNTT), which significantly improved the patency rate and the fistula maturation10. The aim of this technique was to primarily avoid both devascularization of the venous and arterial wall and severing of the radial artery. After the skin and subcutaneous tissue were incised, the cephalic vein and its surrounding adipose tissue were seen below the superficial fascia. An 8-10-mm-long incision was made in the superficial fascia and cephalic vein wall, and the radial artery pedicle (including the radial artery and its accompanying veins) was isolated 40-50 mm. The artery pedicle was not severed, and the radial artery pedicle was raised to approach the cephalic vein. An 8-10-mm-long incision was made in the artery. The anastomosis was performed side-to-side and the distal vein was ligated to form a functional end-to-side anastomosis (Figure 1).
We evaluated blood vessels by Doppler ultrasound before the surgeries of 10 cases: there was no stenosis in the radial artery and cephalic vein with radial artery diameter&#8805;1.6 mm and cephalic vein diameter&#8805;2 mm. Echocardiography showed left ventricular score &#62;60%, and the patient had no surgical contraindications. A distance of &#60;2 cm between the artery and vein was identified as the proposed anastomosis site.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/62784/62784fig01.jpg" /> 
Figure 1. Schematic diagram of anastomosis types in AVFs12. a: Conventional surgery for an AVF. b: AVF created using the NTT. c: AVF created using the MNTT and a functional end-to-side anastomosis. AVF: arteriovenous fistula; NTT: no-touch technique. <a href="https://www.jove.com/files/ftp_upload/62784/62784fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Curved hemostatic forceps</td>
			<td>Xinhua Surgical Instrument Co., Ltd.</td>
			<td>ZH131R/RN</td>
			<td></td>
		</tr>
		<tr>
			<td>Dissecting Forceps</td>
			<td>Xinhua Surgical Instrument Co., Ltd.</td>
			<td>ZDO25R/RN</td>
			<td></td>
		</tr>
		<tr>
			<td>Electrotome</td>
			<td>Changzhou Yanling Electronic Equipment Co., Ltd.</td>
			<td>TY21205812</td>
			<td></td>
		</tr>
		<tr>
			<td>Eyelld Retractor</td>
			<td>Xinhua Surgical Instrument Co., Ltd.</td>
			<td>Z014602T</td>
			<td></td>
		</tr>
		<tr>
			<td>Lidocaine</td>
			<td>Hebei Tiancheng Pharmaceutical Co., Ltd.</td>
			<td>1B200612104</td>
			<td></td>
		</tr>
		<tr>
			<td>Halsey needleholder</td>
			<td>Xinhua Surgical Instrument Co., Ltd.</td>
			<td>ZM208R/RN</td>
			<td></td>
		</tr>
		<tr>
			<td>Micro forceops</td>
			<td>Xinhua Surgical Instrument Co., Ltd.</td>
			<td>ZD275RN/T</td>
			<td></td>
		</tr>
		<tr>
			<td>Micro needle holder forceps</td>
			<td>Xinhua Surgical Instrument Co., Ltd.</td>
			<td>ZF2618RB/T</td>
			<td></td>
		</tr>
		<tr>
			<td>Micro scissors</td>
			<td>Xinhua Surgical Instrument Co., Ltd.</td>
			<td>ZF022T</td>
			<td></td>
		</tr>
		<tr>
			<td>Micro vessel knife</td>
			<td>Xinhua Surgical Instrument Co., Ltd.</td>
			<td>ZF1549RN</td>
			<td></td>
		</tr>
		<tr>
			<td>Non-absorbable suture 3-0</td>
			<td>Ethicon,LLC</td>
			<td>SA84G</td>
			<td></td>
		</tr>
		<tr>
			<td>Poly propylene 7-0</td>
			<td>Ethicon,LLC</td>
			<td>PDB601</td>
			<td></td>
		</tr>
		<tr>
			<td>Sharp blade</td>
			<td>Suzhou Medical Products Factory Co., Ltd.</td>
			<td>TY21232001</td>
			<td></td>
		</tr>
		<tr>
			<td>scalpel handle</td>
			<td>Shanghai Medical Instrument (Group) Co., Ltd. Surgical Instruments Factory</td>
			<td>J11030</td>
			<td></td>
		</tr>
		<tr>
			<td>Syringe with needle (5ml)</td>
			<td>BD medical devices (Shanghai) Co., Ltd</td>
			<td>2006116</td>
			<td></td>
		</tr>
		<tr>
			<td>Triangle needle</td>
			<td>Hangzhou Huawei medical supplies Co., Ltd</td>
			<td>7X17</td>
			<td></td>
		</tr>
		<tr>
			<td>Vessel clamp</td>
			<td>Xinhua Surgical Instrument Co., Ltd.</td>
			<td>ZF220RN</td>
			<td></td>
		</tr>
		<tr>
			<td>Vessel loop</td>
			<td>Shenzhen Yiman Technology Co., Ltd</td>
			<td>EM-SR1</td>
			<td></td>
		</tr>
	</tbody>
</table>

creating radio-cephalic arteriovenous fistula in the forearm with a modified no-touch technique

Autologous arteriovenous fistula (AVF) is the primary and best option to obtain vascular access for hemodialysis treatment; other options are arteriovenous graft (AVG) and central venous catheterization (CVC). The implementation of radio-cephalic autologous arteriovenous fistula (RC-AVF) in the forearm was preferred among patients with superior vascular conditions. However, there is a high rate of early fistula failure. The chosen surgical method is understood to have an effect on the maturation of the fistula. New surgical procedures such as radial artery deviation and reimplantation (RADAR) have been significantly improved for juxta-anastomotic stenosis. Nevertheless, new problems such as stenosis of arteries and narrowing of surgical indication were also found. In this report, we presented a modified no-touch technique (MNTT) to create an RC-AVF, in which the venous and arterial wall avoid devascularization and the radial artery does not sever.

Since January 2021, we have applied the MNTT technique in 10 patients to construct AVF. Seven of the 10 patients have been under dialysis.
None of the patients had fever or infection after surgery. Physical examination of the cephalic-vein at weeks 4 and 8 showed significant dilation. Fistula can be palpable tremor with loud murmur. Doppler ultrasonography showed obvious dilation of the cephalic vein and radial artery. The blood flow spectrum of the cephalic vein 1.5 cm away from the anastomos...

Watch this Scientific Journal Video about Creating Radio-cephalic Arteriovenous Fistula in the Forearm with a Modified No-Touch Technique at JoVE.com

Creating Radio-cephalic Arteriovenous Fistula in the Forearm with a Modified No-Touch Technique

We present a modified no-touch technique (MNTT) to create a radio-cephalic arteriovenous fistula (RC-AVF) in which the venous and arterial wall avoid devascularization and the radial artery does not sever.

Autologous arteriovenous fistula (AVF) is the primary and best option to obtain vascular access for hemodialysis treatment; other options are ...

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7.2K Views.  Nanjing Medical University. We present a modified no-touch technique (MNTT) to create a radio-cephalic arteriovenous fistula (RC-AVF) in which the venous and arterial wall avoid devascularization and the radial artery does not sever.

Video: Creating Radio-cephalic Arteriovenous Fistula in the Forearm with a Modified No-Touch Technique

Modified Technique for Coronary Artery Ligation in Mice

Myocardial infarction (MI) is one of the most important causes of mortality in humans1-3. In order to improve morbidity and mortality in patients with MI we need better knowledge about pathophysiology of myocardial ischemia. This knowledge may be valuable to define new therapeutic targets for innovative cardiovascular therapies4. Experimental MI model in mice is an increasingly popular small-animal model in preclinical research in which MI is induced by means of permanent or temporary ligation of left coronary artery (LCA)5. In this video, we describe the step-by-step method of how to induce experimental MI in mice.
The animal is first anesthetized with 2% isoflurane. The unconscious mouse is then intubated and connected to a ventilator for artificial ventilation. The left chest is shaved and 1.5 cm incision along mid-axillary line is made in the skin. The left pectoralis major muscle is bluntly dissociated until the ribs are exposed. The muscle layers are pulled aside and fixed with an eyelid-retractor. After these preparations, left thoracotomy is performed between the third and fourth ribs in order to visualize the anterior surface of the heart and left lung. The proximal segment of LCA artery is then ligated with a 7-0 ethilon suture which typically induces an infarct size ~40% of left ventricle. At the end, the chest is closed and the animals receive postoperative analgesia (Temgesic, 0.3 mg/50 ml, ip). The animals are kept in a warm cage until spontaneous recovery.

The surgical procedure used to induce experimental myocardial infarction in mice begins with left thoracotomy between the third and the fourth ribs in order to visualize the anterior surface of the heart and left lung. The left coronary artery is ligated, the chest is closed and the mouse is allowed to recover spontaneously.

Myocardial infarction (MI) is one of the most important causes of mortality in humans1-3. In order to improve morbidity and mortality in patients with MI ...

Technical Aspects of the Mouse Aortocaval Fistula

Technical aspects of creating an arteriovenous fistula in the mouse are discussed. Under general anesthesia, an abdominal incision is made, and the aorta and inferior vena cava (IVC) are exposed. The proximal infrarenal aorta and the distal aorta are dissected for clamp placement and needle puncture, respectively. Special attention is paid to avoid dissection between the aorta and the IVC. After clamping the aorta, a 25 G needle is used to puncture both walls of the aorta into the IVC. The surrounding connective tissue is used for hemostatic compression. Successful creation of the AVF will show pulsatile arterial blood flow in the IVC. Further confirmation of successful AVF can be achieved by post-operative Doppler ultrasound.

The goal is to produce an arteriovenous fistula that is simple and reproducible. This method does not use sutures or glue adhesive. Therefore the samples can be used with the least amount of foreign materials for analysis.

Technical aspects of creating an arteriovenous fistula in the mouse are discussed. Under general anesthesia, an abdominal incision is made, and the aorta ...

Human Skeletal Muscle Biopsy Procedures Using the Modified Bergstr&#246;m Technique

The percutaneous biopsy technique enables researchers and clinicians to collect skeletal muscle tissue samples. The technique is safe and highly effective. This video describes the percutaneous biopsy technique using a modified Bergstr&#246;m needle to obtain skeletal muscle tissue samples from the vastus lateralis of human subjects. The Bergstr&#246;m needle consists of an outer cannula with a small opening (&#8216;window&#8217;) at the side of the tip and an inner trocar with a cutting blade at the distal end. Under local anesthesia and aseptic conditions, the needle is advanced into the skeletal muscle through an incision in the skin, subcutaneous tissue, and fascia. Next, suction is applied to the inner trocar, the outer trocar is pulled back, skeletal muscle tissue is drawn into the window of the outer cannula by the suction, and the inner trocar is rapidly closed, thus cutting or clipping the skeletal muscle tissue sample. The needle is rotated 90&#176;&#160;and another cut is made. This process may be repeated three more times. This multiple cutting technique typically produces a sample of 100-200 mg or more in healthy subjects and can be done immediately before, during, and after a bout of exercise or other intervention. Following post-biopsy dressing of the incision site, subjects typically resume their activities of daily living right away and can fully participate in vigorous physical activity within 48-72 hr. Subjects should avoid heavy resistance exercise for 48 hr to reduce the risk of herniation of the muscle through the incision in the fascia.

The purpose of this video is to present the modified Bergstr&#246;m skeletal muscle biopsy technique on human subjects.

The percutaneous biopsy technique enables researchers and clinicians to collect skeletal muscle tissue samples. The technique is safe and highly ...

A Novel Murine Model of Arteriovenous Fistula Failure: The Surgical Procedure in Detail

The arteriovenous fistula (AVF) still suffers from a high number of failures caused by insufficient remodeling and intimal hyperplasia from which the exact pathophysiology remains unknown. In order to unravel the pathophysiology a murine model of AVF-failure was developed in which the configuration of the anastomosis resembles the preferred situation in the clinical setting. A model was described in which an AVF is created by connecting the venous end of the branch of the external jugular vein to the side of the common carotid artery using interrupted sutures. At a histological level, we observed progressive stenotic intimal lesions in the venous outflow tract that is also seen in failed human AVFs. Although this procedure can be technically challenging due to the small dimensions of the animal, we were able to achieve a surgical success rate of 97% after sufficient training. The key advantage of a murine model is the availability of transgenic animals. In view of the different proposed mechanisms that are responsible for AVF failure, disabling genes that might play a role in vascular remodeling can help us to unravel the complex pathophysiology of AVF failure.

Here we present a murine model of arteriovenous fistula (AVF) failure in which a clinically relevant anastomotic configuration is incorporated. This model can be used to study the pathophysiology and to test possible therapeutic interventions.

The arteriovenous fistula (AVF) still suffers from a high number of failures caused by insufficient remodeling and intimal hyperplasia from which the ...

Intraluminal Drug Delivery to the Mouse Arteriovenous Fistula Endothelium

Delivery of therapeutic agents to enhance arteriovenous fistula (AVF) maturation can be administered either via intraluminal or external routes. The simple murine AVF model was combined with intraluminal administration of drug solution to the venous endothelium at the same time as fistula creation. Technical aspects of this model are discussed. Under general anesthesia, an abdominal incision is made and the aorta and inferior vena cava (IVC) are exposed. The infra-renal aorta and IVC are dissected for clamping. After proximal and distal clamping, the puncture site is exposed and a 25 G needle is used to puncture both walls of the aorta and into the IVC. Immediately after the puncture, a reporter gene-expressing viral vector was infused in the IVC via the same needle, followed by 15 min of incubation. The intraluminal administration method enabled more robust viral gene delivery to the venous endothelium compared to administration by the external route. This novel method of delivery will facilitate studies that explore the role of the endothelium in AVF maturation and enable intraluminal drug delivery at the time of surgical operation.

After puncturing the aorta through the inferior vena cava (IVC) to create an aorto-caval fistula in the mouse, solution containing a drug is infused into the IVC via the same needle, followed by incubation. This method enables more robust drug delivery to the venous endothelium compared to the external route.

Delivery of therapeutic agents to enhance arteriovenous fistula (AVF) maturation can be administered either via intraluminal or external routes. The ...

Mouse Model for Pancreas Transplantation Using a Modified Cuff Technique

Mouse models have several advantages in transplantation research, including easy handling, a variety of genetically well-defined strains, and the availability of the widest range of molecular probes and reagents to perform in vivo as well as in vitro studies. Based on our experience with various murine transplantation models, we developed a heterotopic pancreas transplantation model in mice with the intent to analyze mechanisms underlying severe ischemia reperfusion injury-associated early graft damage. In contrast to previously described techniques using suture techniques, herein we describe a new procedure using a non-suture cuff technique. 
In recent years, we have performed more than 300 pancreas transplantations in mice with an overall success rate of &gt;90%, a success rate never described before in mouse pancreas transplantation. The backbone of this non-suture cuff technique for graft revascularization consists of two major steps: (I) pulling the recipient vessel over a polyethylene/polyamide cuff and fixing it with a circumferential ligature, and (II) placing the donor vessel over the everted recipient vessel and fixing it with a second circumferential ligature. The resultant continuity of the endothelial layer results in less thrombogenic lesions with high patency rates and, finally, high success rates.
In this model, arterial anastomosis is achieved by pulling the abdominal aorta of the donor graft over the everted common carotid artery of the recipient animal. Venous drainage of the graft is achieved by pulling the portal vein of the graft over the everted external jugular vein of the recipient. This manuscript provides details and crucial steps of the organ recovery and organ implantation procedures, which will allow researchers with microsurgical skills to perform the transplantation successfully in their laboratories.

Among abdominal solid organ transplantation, pancreatic grafts are prone to develop severe ischemia reperfusion injury-associated graft damage, leading eventually to early graft loss. This protocol describes a model of murine pancreas transplantation using a non-suture cuff technique, ideally suited for analyzing these early, deleterious damages.

Mouse models have several advantages in transplantation research, including easy handling, a variety of genetically well-defined strains, and the ...

Modified Technique for the Use of Neonatal Murine Hearts in the Langendorff Preparation

The use of the ex-vivo retrograde perfused heart has long been a cornerstone of ischemia-reperfusion investigation since its development by Oskar Langendorff over a century ago. Although this technique has been applied to mice over the last 25 years, its use in this species has been limited to adult animals. Development of a successful method to consistently cannulate the neonatal murine aorta would allow for the systematic study of the isolated retrograde perfused heart during a critical period of cardiac development in a genetically modifiable and low-cost species. Modification of the Langendorff preparation enables cannulation and establishment of reperfusion in the neonatal murine heart while minimizing ischemic time. Optimization requires a two-person technique to permit successful cannulation of the newborn mouse aorta using a dissecting microscope and a modified commercially available needle. The use of this approach will reliably establish retrograde perfusion within 3 min. Because the fragility of the neonatal mouse heart and ventricular cavity size prevents direct measurement of intraventricular pressure generated using a balloon, use of a force transducer connected by a suture to the apex of the left ventricle to quantify longitudinal contractile tension is necessary. This method allows investigators to successfully establish an isolated constant-flow retrograde-perfused newborn murine heart preparation, permitting the study of developmental cardiac biology in an ex-vivo manner. Importantly, this model will be a powerful tool to investigate the physiological and pharmacological responses to ischemia-reperfusion in the neonatal heart.

The present protocol describes aortic cannulation and retrograde perfusion of the ex-vivo neonatal murine heart. A two-person strategy, using a dissecting microscope and a blunted small gauge needle, permits reliable cannulation. Quantification of longitudinal contractile tension is achieved using a force transducer connected to the apex of the left ventricle.

The use of the ex-vivo retrograde perfused heart has long been a cornerstone of ischemia-reperfusion investigation since its development by Oskar ...

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic resection and reconstruction techniques, it is difficult to perform LPD for patients with locally advanced pancreatic head cancer after neoadjuvant therapy. Our team initiates LPD using the in-situ No-Touch isolation technique. The innovation and optimization of this modified No-Touch isolation technique emphasize exploring the distal section of superior mesenteric vein&#160;(SMV) and the left side of the superior mesenteric artery (SMA) prior to evaluating the resectability by subcolonic mesenteric approach, which is an ideal exploring approach. After that, we use the median-anterior, and left-posterior of SMA approaches to cut off the blood flow of the pancreatic head to make the tumor isolated intact, then move and dissect the tumor. It is a process fitting the surgical principle of tumor-free. This article aims to demonstrate the feasibility and safety of performing LPD using the in-situ No-Touch isolation technique, which might elevate the R0 resection rate. It is an oncological ideal operation process.

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

No-Touch isolation procedures might prevent the dissemination of cancer cells from the primary tumor. However, these techniques are not widely accepted in laparoscopic pancreatoduodenectomy (LPD) by now. We herein present in-situ No-Touch isolation LPD with partial resection and reconstruction of the superior mesenteric vein (SMV) for pancreatic cancer after neoadjuvant therapy.

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic ...

Modified Posterior Vertebral Column Resection for Patients with Thoracolumbar Kyphotic Deformity

Old compression vertebrae fracture or congenital kyphoscoliosis with abnormal vertebral body development and other diseases that invade the spine may cause severe thoracolumbar kyphotic deformity, often accompanied by intractable low back pain or compression of the spinal cord, leading to severe neurological symptoms or even paralysis. If conservative treatment cannot relieve the symptoms or correct the deformities, surgical treatment is usually needed. For severe kyphotic deformity, reconstruction of the physiological curvature and rigid fixation determine the prognosis of the patients. Osteotomy and orthopedics are the standard procedure for deformities with severe compression of the front and middle column, but the trauma to the patients is high, with a long operation time and massive blood loss. To avoid these disadvantages, we have developed a modified technique to remove the diseased vertebra unilaterally. In this technique, we use a modified trephine to resect the vertebral columns like in the pedicle screw technique by adding a locking instrument that can restrict the trephine to lower the risk of osteotomy and shorten the surgery time and blood loss.

We describe a modified technique for resecting the posterior vertebral column unilaterally based on a modified trephine for patients with thoracolumbar kyphotic deformity.

Old compression vertebrae fracture or congenital kyphoscoliosis with abnormal vertebral body development and other diseases that invade the spine may ...

A Modified Technique for Arteriovenous Fistula Construction in Rabbits

Juxta-anastomotic stenosis is a challenging problem that often causes non-maturation and decreases the patency of an arteriovenous fistula (AVF). Injury to the veins and arteries during the operation and hemodynamic changes can lead to intimal hyperplasia, leading to juxta-anastomotic stenosis. To reduce injury to the veins and arteries during the operation, this study proposes a new modified no-touch technique (MNTT) for AVF construction that can decrease the rate of juxta-anastomotic stenosis and improve the AVF patency. To unravel the hemodynamic changes and mechanisms of the MNTT, this study presented an AVF procedure using this technique. Although this procedure is technically challenging, 94.4% procedural success was achieved after adequate training. Ultimately, 13 out of 34 rabbits had a functional AVF 4 weeks after the surgery, leading to a 38.2% AVF patency rate. However, at 4 weeks, the survival rate was 86.1%. Ultrasonography showed active blood flow through AVF anastomosis. Furthermore, the spiral laminar flow was observed in the vein and artery near the anastomosis, suggesting that this technique may improve the hemodynamics of the AVF. On histological observation, significant venous intimal hyperplasia was observed at the AVF anastomosis, whereas no significant intimal hyperplasia was observed at the proximal external jugular vein (EJV) of the anastomosis. This technique will improve the understanding of the mechanisms underlying the use of MNTT for AVF construction and provide technical support for the further optimization of the surgical approach in AVF construction.

The present protocol proposes the creation of an arteriovenous fistula in rabbits using a modified no-touch technique. The technique involves the side-to-side anastomosis of the common carotid artery and external jugular vein without the dissection of the perivenous tissues or cutting off the artery.

Juxta-anastomotic stenosis is a challenging problem that often causes non-maturation and decreases the patency of an arteriovenous fistula (AVF). Injury ...