Performing quality control during peripheral bypass surgery is important to secure optimal patency of the graft to avoid re-operation or secondary intervention. In this case, Transit Time Flow Measurement (TTFM), High-Frequency Ultrasound (HFUS), and angio verified distal flow before closing the wounds.

Patient information

• 67-year-old male • Occlusion of the left superficial femoral artery • Vascular ulcer above left ankle (Figure 1)

This case demonstrates how Transit Time Flow Measurement (TTFM) can be used during liver transplant surgery as a guide when modulating the portal venous flow (PVF) to avoid hepatofugal flow. Hepatofugal flow or non-forward portal flow (NFPF) describes a blood flow that is directed away from the liver. Hepatofugal flow in the portal venous system is, with few exceptions, always pathological. Detection of NFPF is important as it has been shown to be associated with poorer clinical outcome after liver transplantation. See image 1

This case demonstrates how High-Frequency Ultrasound (HFUS) can detect thrombus in the hepatic artery even when Transit Time Flow Measurement (TTFM) did not reveal any flow related issues. The case example consists only of a set of measurements and images using the MiraQ^TM during the surgery without further comments from the surgeon.

This case demonstrates how Transit Time Flow Measurement (TTFM) can be used during liver transplant surgery to detect technical errors.

This case demonstrates how Transit Time Flow Measurement (TTFM) and High-Frequency Ultrasound (HFUS) were instrumental in avoiding a catastrophic incident. A thrombus in the saphenous vein graft (SVG) was detected during surgery. Meso-Rex shunt is a surgical procedure that restores physiological portal venous blood flow to the liver by using a graft to connect the superior mesenteric vein and the left portal vein within the Rex recess.

This case shows the benefit of using Transit Time Flow Measurement (TTFM) in addition to High-Frequency Ultrasound (HFUS) after CEA when dealing with a kinked ICA. Finding kinks like these before performing CEA are not uncommon in elderly people. The surgeon decided not to repair the kink since it could result in more kinks upstream causing further problems. Nor did he shorten the artery since it might increase the risk of creating an unwanted flap. When he measured the flow with TTFM after CEA, he found it satisfactory hence avoiding further revision.

This case shows that the expectation of a huge increase in flow is not always met in every case. However, a significant change in the flow curve can be seen. HFUS revealed intima flaps that are not visible on angiography. When checking the clamping sites and the intima steps in the ICA and ECA after CEA, minor residual intima flaps were detected but did not lead to a revision.

Patient medical history: Patient with PAD and Fontaine stage IV on the right side. See image 1. Initial surgery: Fem-pop bypass. The surgery went uneventfully and the TTFM showed 41 ml/min with a PI of 2,9 after ligation of all residual saphenous vein side branches that were visible on angio, as seen in image 2.

This case illustrates a low-flow situation of a Cimino fistula on the left forearm with a juxta-anastomotic stenosis. Transit Time Flow Measurement (TTFM) and High-frequency Ultrasound Imaging (HFUS) served as completion control.

This case example shows a routine fem-pop case where the surgeon assessed the quality of the bypass procedure using all 3 measurement technologies provided by the MiraQ system; High-frequency ultrasound imaging, TTFM and PW Doppler measurements.