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.

Split-liver transplantation (LT) allows transplantation of two recipients from one deceased donor, thereby increasing pool of grafts. However, split LT may be hampered by technical problems, and split grafts are still considered suboptimal organs in some centres. We analysed the outcomes in split- and whole-liver recipients in a combined adult-to-paediatric transplantation programme. Records of paediatric and adult patients having undergone LT from 1999 to 2013 were analysed retrospectively. All splits were performed in situ. Adult split-graft recipients were matched 1:2 with whole-graft recipients (matching criteria: BMI, MELD, year of transplantation, age), and matched to the paediatric recipient transplanted from the same donor. Post-LT complications were classified according to the Clavien scale. Among children, 32 split- and 31 whole-graft recipients were analysed. Among adults, 20 split- and 40 matched whole-graft recipients were analysed. In both populations, the post-operative complications did not differ between split- and whole-graft recipients. There was no difference in 1-year graft and patient survival between split- and whole-graft recipients in paediatric (90% vs. 97%, 94% vs. 97%, respectively) and in adult recipients (89% in both, 89% vs. 92%, respectively). In the analysis of both recipients issued from the same donor, there was no association in the prevalence and severity of complications. A case-by-case analysis showed that split mortality was unrelated to LT in all but one patient (small-for-size left split graft). In the setting of careful donor selection, recipient matching and surgical skill, in situ split LT is an effective and safe technique to increase the number of available organs, and split livers should no longer considered marginal grafts.

The absence of any major permanent neurologic deficit or any visceral damages in our patients suggests that continuous moderate hypothermic cerebral perfusion, with an interval of circulatory arrest of the lower body, is adequate for acute type A aortic dissection surgery, allowing safe open repair of the distal aortic arch.

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SummaryWe 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) ЊC and 1.3 (0.5) ЊC 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. (Br. J. Anaesth. 1998; 80: 318-323) Keywords: temperature, body; equipment, warming devices; surgery, cardiovascular; blood, coagulation; hypothermia Hypothermia remains a common problem because of its deleterious haemodynamic, haemostatic, immune and metabolic effects.1-4 After non-cardiac surgery, mild hypothermia has also been associated with arterial hypertension and myocardial ischaemia, 5 in addition to increased blood loss. 6 Patients undergoing cardiac surgery are often cooled to nasopharyngeal temperatures of 26-28 ЊC. At the end of cardiopulmonary bypass (CPB), even though nasopharyngeal temperature is restored to pre-bypass levels, a considerable mass of peripheral tissues remains at subnormal temperatures; subsequent redistribution of heat from the core to the periphery causes a decrease in nasopharyngeal temperature ranging from 1 to 3 ЊC, termed "afterdrop".7 8 During operation, adopting a "normothermic" bypass technique, prolonging the rewarming period or infusing vasodilators while increasing pump flow may attenuate the postoperative central temperature afterdrop. 9 In the intensive care unit (ICU), external heat, that is convective or radiant, applied over a large body surface area has been shown to accelerate rewarming with the benefits of less shivering, lower oxygen demand and more haemodynamic stability. [10][11][12][13] Although skin surface warming with a forced warm air device is a simple, safe and efficient means for preventing hypothermia during major surgical procedures, 14 it has not yet been recommended for use during cardiac surgery because the body surface area available for cutaneous warming was thought to be too small.As the afterdrop in nasopharyngeal temperature is attributed to redistribut...