A Novel Technique of Subclavian Artery Cannulation for Venoarterial Extracorporeal Membrane Oxygenation.

OBJECTIVES: The common femoral artery is the standard site for immediate vascular access when initiating adult venoarterial extracorporeal membrane oxygenation. However, this approach is fraught with problems such as femoral artery occlusion, distal limb ischemia, reperfusion injury resulting in compartment syndrome, retroperitoneal hemorrhage, thrombosis, embolization, and most importantly, pulmonary edema. Here, we show our preference of using the subclavian artery with a side graft as a different cannulation technique for outflow of extracorporeal membrane oxygenation, which can avoid complications associated with different access techniques. MATERIALS AND METHODS: Between September 2013 and December 2014, our group established venoarterial extracorporeal membrane oxygenation via subclavian artery-percutaneous femoral vein cannulation in 11 patients (81.1% men). Mean age was 33 ± 11.1 years (range, 16-55 y). RESULTS: For this technique, the subclavian artery was slung by retrotapes (Retract-o-Tape; Quest Medical Inc. Allen, TX, USA) proximally and distally before arteriotomy. An 8-mm polyethylene terephthalate (Dacron) graft was then sutured in "end-to-side" fashion. The proximal retrotape was removed, and the distal retrotape was passed through a snare. This maneuver allowed us to manage distal flow of subclavian artery by tightening this tape, thus avoiding complications associated with right arm hyperperfusion. After venoarterial extracorporeal membrane oxygenation was established, central venous pressure and lactate levels decreased, and improvements in arterial blood-gas parameters were maintained. CONCLUSIONS: Our protocol for venoarterial extracorporeal membrane oxygenation cannulation uses the subclavian artery for arterial access and provides a safe and perhaps improved means for providing venoarterial extracorporeal membrane oxygenation support.

Low-Dose Valacyclovir for Cytomegalovirus Infection Prophylaxis After a Heart Transplant.

OBJECTIVES: Cytomegalovirus infection is a major cause of morbidity and mortality in solid-organ transplant. Low doses of valacyclovir have been administered as cytomegalovirus prophylaxis in our institution for years. To the best of our knowledge, there is no published study of a low-dose regimen for cytomegalovirus prophylaxis in heart transplant patients. Therefore, our aim was to determine the results of low doses of valacyclovir in heart transplant. MATERIALS AND METHODS: Between September 2006 and December 2014, sixty-eight patients underwent orthotopic heart transplants. All of the patients received triple immunosuppressive therapy after surgery. During the next 6 months, sulfamethoxazole/trimethoprim was administered for Pneumocystis jiroveci pneumonia, and toxoplasmosis. Additionally all patients received valacyclovir hydrochloride (1000 mg/d, oral) for cytomegalovirus prophylaxis and nystatin oral rinse for prophylaxis of fungal infections. RESULTS: There was only 1 cytomegalovirus infection at follow-up. The patient had cytomegalovirus pneumonia at 17-month follow-up. In response to treatment with 1-week intravenous ganciclovir, the patient was discharged with a further 6-month oral valacyclovir therapy (1000 mg/d). CONCLUSIONS: In this study, we hypothesized that daily use of low-dose valacyclovir (1000 mg/d) is not only sufficient for cytomegalovirus prophylaxis but also beneficial in terms of cost.

Preoperative neutrophil-lymphocyte ratio and saphenous vein graft patency after coronary artery bypass grafting.

AIM: The aim of the present study was to investigate the predictive value of preoperative neutrophil-lymphocyte ratio (NLR) in postoperative saphenous vein graft patency in patients undergoing coronary artery bypass grafting (CABG) surgery. METHOD: We retrospectively analyzed 444 patients who had undergone CABG and a further control coronary angiography due to recurrence of symptoms. The patients were divided into tertile groups according to the NLR. The primary end point was 50% saphenous vein graft stenosis or more or complete occlusion. RESULT: The saphenous vein graft failure in the 3 groups based on NLR was 33%, 66.2%, and 79.1%, in the low-, middle- and high-risk groups, respectively. In multivariate regression modeling, current smoker, diabetes mellitus, target artery diameter <1.5 mm, and NLR independently predicted saphenous vein graft patency in patients after CABG. CONCLUSION: Preoperative NLR is clearly an independent predictor of saphenous vein graft patency in patients after CABG.

Thoracic aortic aneurysms after blunt trauma.

BACKGROUND: Aortic injury after blunt trauma that is missed during the first admission will soon be seen as a chronic aneurysm. The objective of this study is to show the importance of the diagnosis and appropriate treatment of these aneurysms. METHODS: Between 2009 and 2012, 8 patients (mean age, 50±31 years) diagnosed with chronic traumatic aortic aneurysm were treated with either thoracic endovascular aortic repair (TEVAR) or conventional surgery 20 years on average after the trauma. RESULTS: Treatments included TEVAR in four patients, conventional surgery in two patients, and hybrid intervention in one patient. One patient died postoperatively. One patient had an endoleak requiring a repeat TEVAR, which was successful. Brachial embolectomy was performed after placing the endovascular stent. No paraplegia or lower extremity ischemia was seen. One patient died preoperatively due to rupture of the aneurysm. CONCLUSION: Chronic traumatic aortic aneurysms may cause general symptoms years after a blunt trauma. Aortic injury must always be considered in the assessment and follow-up of trauma patients.