Intraoperative flow measurements in gastroepiploic grafts using pulsed Doppler 1

Abstract Objective: The patency of a pedicled right gastroepiploic artery (RGEA) graft can be compromised by intraoperative twists, kinks or spasms. Therefore, a systematic flow assessment was made in RGEA grafts and was compared with similar measurements made in other types of bypass conduits. Methods: Intraoperative pulsed Doppler flowmeter measurements obtained in a series of 556 consecutive patients undergoing at least one coronary bypass grafting onto the right coronary system were studied. Eighty-five RGEA grafts were compared with 1427 bypass grafts implanted in the same group of patients and consisted of the following conduits: 442 left internal mammary (LIMA), 149 right internal mammary (RIMA), 831 greater saphenous vein (GSV) and five inferior epigastric (EPIG) grafts. Sequential grafts were excluded from the analysis. Results: Flow measurements and Doppler waveforms were abnormal and required graft repositioning, and the addition of a distal graft or intragraft papaverine injection (only in GSVs) in 29 cases (2.0% of all grafts). These graft corrections were necessary in 5.9% RGEAs, 3.4% LIMAs, 2.0% RIMAs, and 0.7% GSVs (P Ͻ 0.001). The relative risk for graft correction was eight times higher for RGEAs than for GSVs (P = 0.002). Flow increased from 8 ± 2 to 54 ± 5 ml/min (P Ͻ 0.0001). Flow data were significantly influenced by the type of run-off bed (P Ͻ 0.001), the measurements obtained in grafts implanted onto the right coronary artery and the left anterior descending artery being superior. Flows in RGEAs, however, were comparable with values obtained in other grafts implanted onto the same recipient coronary artery. Conclusions: A significantly higher incidence of graft malpositioning caused inadequate flows in RGEAs. However, normal flow values could be restored simply by assigning a better graft orientation under pulsed Doppler flowmeter control. Overall flow capacity of the RGEA did not differ from values obtained in other arterial and venous grafts implanted onto the same recipient arteries

Hyperoxygenation of the operating field can prevent hypoxia during open surgery of the distal airway under high-frequency jet ventilation.

The use of high-frequency jet ventilation (HFJV) during distal trachea surgery and carina surgery has long been documented.1 and 2 Nonetheless, in most cases, controlling the patient's oxygenation requires a substantial increase in the fraction of inspired oxygen (FIO2) used by the HFJV, which, in our experience, varies between 50% and 100%. In these operative conditions, surgical opening of the distal trachea or of the carina inevitably is accompanied by a mixing of the gases administered to the patient by HFJV and the surrounding air present in the operating room, owing to the Venturi effect. This mixing is rapidly followed by a reduction in the FIO2 distributed to the patient and a significant arterial desaturation

Traitement chirurgical d’un pseudo-anévrysme post-traumatique de l’artère subclavière droite

Un traumatisme de l'artère subclavière proximale droite est peu fréquent et tend à être associé à la formation d'un pseudoanévrysme. Actuellement, le traitement de choix consiste en une exclusion du pseudo-anévrysme par un stent placé par voie endovasculaire. La chirurgie ouverte est un défi chirurgical en raison de la position anatomique de l’artère subclavière et est associée à un taux élevé de morbidité et de mortalité. Nous présentons le cas d'un patient de 71 ans ayant un pseudoanévrysme de l'artère subclavière proximale droite 11 ans après un accident de voiture. L’objectif est de démontrer que la pathologie a été traitée avec succès par chirurgie vasculaire après échecs de plusieurs procédures endovasculaires. Un pontage aorto-carotido-subclavier droit a été réalisé par abord combiné associant une sternotomie complète à une cervicotomie droite. Le suivi à 6 semaines confirme l’exclusion du pseudo-anévrysme et la perméabilité des troncs revascularisés

Chronic necrotising aspergillosis mimicking ACTH-secreting tumour in a case of Cushing's disease

An 18-year-old man presenting with speech and behaviour disorders was found to suffer from Cushing's syndrome. Ectopic ACTH secretion was initially suspected on the basis of very high cortisoluria and ACTH concentrations, severe hypokalemia, a lung hypermetabolic lesion and a normal pituitary on conventional magnetic resonance imaging (MRI). After lung surgery, this lesion proved to be chronic necrotising aspergilloosis (CNA). Diagnostic reevaluation by bilateral inferior petrosal sinus sampling disclosed a right-sided petrosal sinus gradient consistent with Cushing's disease (CD). A new high resolution thin-section MRI demonstrated a 5 mm pituitary adenoma, which could be removed successfully. Thus, a lung mass associated with several clues in favour of ectopic ACTH secretion may hide a diagnosis of CD. Such a mass can be CNA, an opportunistic infection favoured by immunosuppression, which to our knowledge, is the first case reported in CD

Intraoperative flow measurements in gastroepiploic grafts using pulsed Doppler.

OBJECTIVE: The patency of a pedicled right gastroepiploic artery (RGEA) graft can be compromised by intraoperative twists, kinks or spasms. Therefore, a systematic flow assessment was made in RGEA grafts and was compared with similar measurements made in other types of bypass conduits. METHODS: Intraoperative pulsed Doppler flowmeter measurements obtained in a series of 556 consecutive patients undergoing at least one coronary bypass grafting onto the right coronary system were studied. Eighty-five RGEA grafts were compared with 1427 bypass grafts implanted in the same group of patients and consisted of the following conduits: 442 left internal mammary (LIMA), 149 right internal mammary (RIMA), 831 greater saphenous vein (GSV) and five inferior epigastric (EPIG) grafts. Sequential grafts were excluded from the analysis. RESULTS: Flow measurements and Doppler waveforms were abnormal and required graft repositioning, and the addition of a distal graft or intragraft papaverine injection (only in GSVs) in 29 cases (2.0% of all grafts). These graft corrections were necessary in 5.9% RGEAs, 3.4% LIMAs, 2.0% RIMAs, and 0.7% GSVs (P < 0.001). The relative risk for graft correction was eight times higher for RGEAs than for GSVs (P = 0.002). Flow increased from 8 +/- 2 to 54 +/- 5 ml/min (P < 0.0001). Flow data were significantly influenced by the type of run-off bed (P < 0.001), the measurements obtained in grafts implanted onto the right coronary artery and the left anterior descending artery being superior. Flows in RGEAs, however, were comparable with values obtained in other grafts implanted onto the same recipient coronary artery. CONCLUSIONS: A significantly higher incidence of graft malpositioning caused inadequate flows in RGEAs. However, normal flow values could be restored simply by assigning a better graft orientation under pulsed Doppler flowmeter control. Overall flow capacity of the RGEA did not differ from values obtained in other arterial and venous grafts implanted onto the same recipient arteries