[Minimal invasive cardiac surgery]. / Chirurgie cardiaque minimalement invasive.

With the advent of cardiopulmonary bypass in 1953, complex intracardiac procedures were developed and a full sternotomy was established as the standard approach for these. With this technique, cardiac surgery achieved excellent immediate and long-term results that became the gold standard in a variety of cardiac pathologies, both congenital and acquired. By the late 90's, new techniques were developed, associated with less surgical trauma, decreased postoperative pain and faster functional recovery. Today, in specialized centres, minimally invasive cardiac surgery has been shown to achieve comparable and even better results than conventional surgery. It is rapidly becoming a new standard for valvular heart surgery.

Risk factors for early failure of native arteriovenous fistulas.

INTRODUCTION: Current guidelines recommend native arteriovenous fistulas (AVF) as the vascular access of choice for hemodialysis on account of the lower incidence of complications. However, this kind of vascular access has a high rate of early failure (early thrombosis or non-maturation). Our aim was to examine whether clear risk factors for early AVF failure could be identified in our patients. SUBJECTS AND METHODS: Data of all patients who underwent creation of an AVF at the Geneva University Hospital from January 1998 to December 2002 were reviewed. Early failure was defined as a non-functioning fistula (thrombosis or absence of fistula maturation). RESULTS: 119 patients underwent the creation of 148 native AVF, 88 (59.5%) in the forearm and 60 (40.5%) in the upper arm. 48 (32.4%) fistulae were created in diabetic patients. In a multiple logistic regression analysis, significant predictive factors of early failure were a distal location (adjusted odds ratio (aOR) = 8.21, 95% CI = 2.63-25.63, p < 0.001), female gender (aOR = 4.04, 95% CI = 1.44-11.30, p = 0.008), level of surgical expertise (aOR = 3.97, 95% CI = 1.39-11.32, p = 0.010) and diabetes mellitus (aOR = 3.19, 95% CI = 1.17-8.71, p = 0.024). CONCLUSION: Early failure of AVF occurs mainly in forearm sites among women and diabetic patients. Surgical expertise has also a significant influence. These results suggest that selection of a distal site for a native AVF has to be rigorously made for women and diabetic patients and that surgeon's dedication is of primary importance to avoid early AVF failure occurrence.

Adult-to-adult living-donor liver transplantation. A summary of current status and an outline of the program in Geneva.

Living donor liver transplantation is a relatively new procedure in which the right side of the liver is harvested in a healthy donor and transplanted into a recipient. After the first case in 1994, over 3000 cases have been done worldwide. This review summarizes the reasons why the procedure is needed, describes its main technical aspects, highlights the boundaries in which it can be done safely, summarizes the current experience worldwide and describes the main points of the program in our unit. We argue that living-donor transplantation is a viable alternative to a long time on the waiting list for several patients, and it can be performed safely and successfully provided that all precautions are undertaken to minimize the risks in the donor and to increase the chances of a good outcome in the recipients. If these prerequisites are met, and within the framework of a structured multidisciplinary program, we believe that living-donor liver transplantation should be funded by health insurances as a recognized therapeutic option.

Impact of double internal thoracic artery grafts on long-term outcomes in coronary artery bypass grafting.

We performed this study to determine if bilateral internal thoracic artery grafts provide greater benefit than single internal thoracic artery grafts. Six hundred ninety-four consecutive patients who received 2 coronary grafts in a single operation during 1983-1989 were given 10 years of follow-up and then analyzed retrospectively. Group 1 (n=382) received 2 internal thoracic artery grafts, Group 2 (n= 139) received 1 internal thoracic artery graft and 1 saphenous vein graft, and Group 3 (n= 173) received 2 saphenous vein grafts. Patient demographics, preoperative angiographic findings, and operative indications were the same. Hospital mortality rates were 2.6%, 2.2%, and 2.3%, respectively. Hemorrhage, sternal wound infection, mediastinitis, sternal dehiscence, and prolonged ventilatory support showed no group differences. Follow-up over 10 years was complete in 677 survivors. Mortality rates during follow-up were 1.8%, 2.9%, and 4.7%, respectively. Cardiac-related mortality rates were 71%, 75%, and 88%, respectively (Group 1 vs Group 3, P=0.0412). Ten-year survival was better for Group 1 than for Groups 2 and 3 (P=0.0356 and P <0.0001). Cardiac-event-free survival at 10 years was 93% in Group 1, 84% in Group 2, and 74% in Group 3 (all P <0.0001). The use of 2 internal thoracic artery grafts resulted in significantly lower risk of cardiac death and re-intervention, compared with the use of 1 internal thoracic artery, which in turn was superior to the use of vein grafts. Use of double internal thoracic arteries did not increase postoperative complications.

Obtaining a superficial femoral artery graft in adolescents and children with the deep femoral artery transposition.

A new technique to obtain a segment of the superficial femoral artery as an arterial conduit in young patients while an unobstructed peripheral blood flow is maintained by superficial femoral artery-deep femoral artery transposition is illustrated with two clinical examples. The explanted arterial autograft requires no replacement by another graft and provides a conduit of up to 10 cm in length. Excellent results were achieved in both patients at 1 year. This technique is recommended instead of saphenous vein conduits in very young patients because of the risk for late vein degeneration.

[Start of an adult living donor liver transplantation program in Switzerland]. / Début d'un programme adulte de donneurs vivants de foie en Suisse.

The shortage of cadaver organs has prompted transplant centres to seek new sources of grafts. While living-donor left lobe transplantation (segments II and III) is an established procedure for children, living donor right liver transplantation (segments V, VI, VII, VIII), which can provide adequate liver mass for an average-sized adult patient, is technically more demanding and potentially associated with higher risks for the donor. In view of the permanent shortage of organs in Switzerland, we started an adult living donor liver transplantation programme in 1999 with the approval of the Clinical Ethics Committee of Geneva University Hospitals. Donor evaluation was performed only after the recipient had been officially registered for transplantation in the national waiting list. Preoperative evaluation consisted of a preliminary information phase with blood tests and Doppler ultrasonography, a second phase with radiological non invasive investigations (CT scan with volume measurements, magnetic resonance cholangiography) and a third phase including liver biopsy and angiography. A formal psychiatric evaluation was performed in all cases and detailed consent was required. Eight potential donors were investigated, 5 were not retained because of too small right liver or steatosis, and 3 were accepted (wife, son, sister). Living-donor hepatectomy was performed without interrupting the vascular blood flow. The liver graft was perfused ex-situ with University of Wisconsin solution. The grafts were anastomosed to the preserved vena cava of the recipient and the portal and arterial anastomoses were performed without interposition grafts, with short cold ischaemic times in the 3 cases. The graft-to-recipient weight ratio ranged from 1.04 to 1.12%. The grafts worked immediately; the post-operative course in the 3 recipients was unremarkable and no rejection episode occurred. Significant complications were observed in one donor (percutaneously drained bilioma and spontaneously resolved popliteal sensory palsy). Living-donor right liver transplantation is a potentially valuable solution to the increasing shortage of donor organs. The procedure can be performed safely provided stringent criteria for donor selection, for donor-recipient coupling (> 1% graft to body weight ratio) and for centre selection (experience in liver surgery, reduced and split liver transplantation) are applied.

Endovascular repair using vein-covered stents in the carotid artery bifurcation.

The treatment of a bleeding carotid artery pseudoaneurysm in a patient using endovascular repair is described. Vein-covered stents were successfully employed. There were no neurological complications and no recurrent bleeding during 8 months follow up and carotid artery continuity was achieved. Stents covered with saphenous vein may be considered a treatment option for endovascular repair of pseudoaneurysm of the carotid artery.

Paediatric living related intestinal transplantation between two monozygotic twins: a 1-year follow-up.

We report on a syngeneic living related intestinal transplant in a paediatric setting with a 1-year follow-up. This procedure has allowed progressive growth and weight gain of a recipient patient and a resumption of normal activities with full social and familial reintegration.

Lung transplantation: how to perform the venous anastomosis when clamping is too distal.

During lung transplantation, the venous anastomosis is performed between the atrial cuffs of the donor and the receiver. In certain rare circumstances, however, the surgeon may find two veins and no possibility to reposition the clamp more proximally. A simple technique can be used in this case: both veins are reunited and the venous anastomosis carried out as usual between two large lumens.

[Closed trauma of the abdominal aorta--current update]. / Traumatismes fermés de l'aorte abdominale--mise au point.

This study constitutes an update on current knowledge in the literature concerning closed traumas of the abdominal aorta. The morbidity of such lesions, in case of initial survival, depends on both rapid diagnosis and prompt treatment of hypovolemia and ischemia. The presence of associated intestinal lesions renders diagnosis difficult, modifies surgical treatment, and aggravates prognosis.

The blood supply of the lumbrical muscles.

The blood supply of the lumbrical muscles was studied in 100 upper extremities from fresh human cadavers. Layer by layer dissection revealed the existence of different types of vascularity for the four muscles. The injection of coloured latex or Indian ink solution with gelatin showed the complex arterial network of these muscles together with their various sources of blood supply. Four separate sources of blood supply for each of the muscles were found: the superficial palmar arch (SPA), the common palmar digital artery, the deep palmar arch (DPA) and the dorsal digital artery. It was established that there were no anastomoses between the blood vessels of the tendons of the flexor digitorum profundus muscle and those of the lumbrical muscles. Considerable differences were observed in the details of the blood supply of the individual lumbrical muscles.

Benefits of intraoperative skin surface warming in cardiac surgical patients.

We have investigated patients undergoing cardiac surgery with hypothermic bypass to see if the addition of skin surface warming during systemic rewarming on bypass (heated group, n = 43) would improve perioperative thermal balance compared with conventional management without skin warming (control group, n = 43) in an open, randomized, controlled study. Intraoperative skin warming with a water mattress and forced warm air over the face, neck and shoulders attenuated the afterdrop in nasopharyngeal temperature after weaning from bypass (2.3 (1.2) degrees C and 1.3 (0.5) degrees C in the control and heated groups, respectively) (P < 0.05) and resulted in higher rectal temperature 4 h after surgery. Despite similar standard coagulation tests, heated patients had lower blood loss via the chest tubes (600 (264) ml vs 956 (448) ml in control patients) (P < 0.05) and less requirements for i.v. colloid infusion (1662 (404) ml vs 1994 (389) ml) (P < 0.05). There was a significant inverse correlation between rectal temperature on arrival in the ICU and postoperative blood loss (r = 0.57, P < 0.001). These data suggest that additional skin surface warming with a water mattress and forced warm air helped to preserve perioperative thermal balance and may contribute to reduced bleeding after cardiac surgery.

Blood supply of the digital sheath.

One hundred upper extremities from fresh human cadavers aged 20 to 80 years were injected with coloured latex or Indian ink and gelatin. Under the dissecting microscope two main and one occasional source of vascularization of the digital sheath were identified. Originating from the digitopalmar arches, from the proper palmar digital arteries and occasionally from the arcus palmaris superficialis, a complex arterial system supplies the various parts of the digital sheath. The best vascularized area is the floor of the sheath, while the pulleys and the palmar surface of the sheath are less well vascularized. These data may be of interest to those involved in reconstruction of the tendons of the digital flexor muscles.

Aortocaval fistula associated with abdominal aortic aneurysm: a diagnostic challenge.

The purpose of this study is to determine the clinical features with the best preoperative diagnostic value for aortocaval fistulas (ACF) associated with abdominal aortic aneurysm (AAA). A review of our experience of seven patients presenting ACF between 1980 and 1994 as well as an extensive study of the literature provide a clearer picture of the signs and symptoms allowing diagnosis of ACF: edema of the lower extremities and signs of venous hypertension are the most predictive findings; continuous abdominal murmur is noted in 66% of cases and is of good diagnostic value.

Case report of a hypermobile pacemaker: abnormal manifestations and surgical correction.

An abnormally mobile subclavian pacemaker pulse generator in a 49-year-old woman was stabilized by an absorbable mesh graft. This device was successfully replaced 2 years later without any problems. A 4-year follow-up evaluation was uneventful.

Preoperative inhibition of angiotensin-converting enzyme improves systemic and renal haemodynamic changes during aortic abdominal surgery.

We studied 22 patients undergoing aortic surgery, allocated randomly to receive, before induction of anaesthesia, a single i.v. dose of enalapril 50 micrograms kg-1 or saline. During infrarenal aortic cross-clamping, we observed similar reductions in oxygen uptake in the two groups, despite greater systemic oxygen delivery in enalapril-treated patients; angiotensin-converting enzyme inhibition prevented the reduction in cardiac output and attenuated the decrease in glomerular filtration. Changes in glomerular filtration secondary to aortic clamping were related positively to changes in renal plasma flow (r = 0.83 (saline group) and r = 0.65 (enalapril group)). Creatinine clearance on the first day after operation was significantly higher in the enalapril compared with the saline group. We conclude that enalapril pretreatment is effective in improving systemic oxygen delivery, renal plasma flow and glomerular filtration during aortic abdominal surgery.