To identify risk factors in the development of arm edema (AE) after conservative management of breast cancer, the authors prospectively measured differences in upper and lower arm circumference in 282 patients with stage I or II breast cancer who received radiation. AE was defined as a difference of 2.5 cm or more in either measurement between treated and untreated arms. Median follow-up was 37 months (range, 7-109 months). The crude frequency of AE overall was 19.5% (55 patients). In 21 patients (7.4%) AE was transient; 34 patients (12.1%) had persistent AE, which is the focus of this article. The 5-year actuarial incidence of persistent AE was 16%. The crude risk of persistent severe AE was 3.9%. Various factors were examined for their ability to enable prediction of AE. Treatment-related factors did not significantly enable prediction of AE, whereas factors related to patient size, such as body mass index, were strongly associated with both the frequency and severity of AE.

AbstrAct:The radial artery (RA) is a commonly used conduit for coronary artery bypass grafting, and recent studies have demonstrated that it provides superior long-term patency rates to the saphenous vein in most situations. In addition, the RA is also being used with increasing frequency as the access point for coronary angiography and percutaneous coronary interventions. However, there has been concern for many years that these transradial procedures may have a detrimental impact on the function of RA grafts used in coronary artery bypass grafting, and there is now comprehensive evidence that such interventions cause morphologic and functional damage to the artery in situ. Despite this, there remain remarkably few studies investigating the use of previously cannulated RAs as grafts in coronary artery bypass surgery, and there are no clear guidelines on the use of the RA in coronary artery bypass grafting after its catheterization. This article will review concisely the evidence that transradial procedures cause damage to the RA, and discuss the impact this could have on previously cannulated RAs used as coronary artery bypass grafting conduits. On the basis of the evidence assessed, we make a number of recommendations to both surgeons and cardiologists regarding use of the RA in cardiovascular procedures.

For infants, children, and adolescents with progressive advanced lung disease, lung transplantation represents the ultimate therapy option. Fortunately, outcomes after pediatric lung transplantation have improved in recent years now producing good long‐term outcomes, no less than comparable to adult lung transplantation. The field of pediatric lung transplantation has rapidly advanced; thus, this review aims to update on important issues such as transplant referral and assessment, and extra‐corporal life support as “bridge to transplantation”. In view of the ongoing lack of donor organs limiting the success of pediatric lung transplantation, donor acceptability criteria and surgical options of lung allograft size reduction are discussed. Post‐transplant, immunosuppression is vital for prevention of allograft rejection; however, evidence‐based data on immunosuppression are scarce. Drug‐related side effects are frequent, close therapeutic drug monitoring is highly advised with an individually tailored patient approach. Chronic lung allograft dysfunction (CLAD) remains the Achilles' heel of pediatric lung transplant limiting its long‐term success. Unfortunately, therapy options for CLAD are still restricted. The last option for progressive CLAD would be consideration for lung re‐transplant; however, numbers of pediatric patients undergoing lung re‐transplantation are very small and its success depends highly on the optimal selection of the most suitable candidate.

OBJECTIVES The different mechanical and vasodilatory properties of arteries and veins may influence their flow profiles when used for coronary artery bypass grafting (CABG). This may be of significance when assessing the cut-off values for adequate flow. However, conduit-related flow differences are less examined. METHODS In a study of 268 patients, transit time flowmetry parameters of 336 arterial and 170 venous conduits all grafted to the left coronary territory were compared. With transit time flowmetry, the mean graft flow (MGF), pulsatility index, percentage of diastolic filling and percentage of backwards flow were measured. Conduit-related differences were further compared according to on- or off-pump CABG (ONCABG versus OPCABG) surgery. RESULTS Overall MGF and pulsatility index were comparable between arterial and venous grafts, but in arterial grafts, MGF was higher during ONCABG than during OPCABG (49.1 ± 35.3 ml/min vs 38.8 ± 26.6 ml/min; P = 0.003). Percentage of diastolic filling was higher in arterial grafts than in venous grafts (overall 71.0 ± 7.9% vs 63.7 ± 11.1%; ONCABG 69.9 ± 7.1% vs 63.9 ± 10.4%; OPCABG 71.9 ± 8.3% vs 63.4 ± 12.2%; all P < 0.001). Furthermore, percentage of backwards flow was higher in arterial grafts than in venous grafts in the overall (2.3 ± 3.2% vs 1.7 ± 3.2%, P = 0.002) and in the ONCABG (2.3 ± 3.2% vs 1.3 ± 2.5%, P < 0.001) cohorts. In venous grafts, percentage of backwards flow was lower during ONCABG versus OPCABG (1.3 ± 2.5% vs 2.6 ± 3.9%, P = 0.016). CONCLUSIONS No statistically significant difference was observed for MGF and pulsatility index between arterial and venous conduits. However, arterial grafts have significantly higher diastolic filling and backwards flow than venous grafts. Furthermore, arterial grafts have a significantly higher MGF in ONCABG versus OPCABG.

A best evidence topic in cardiovascular surgery was written according to a structured protocol. The question addressed was whether patients with severe asymptomatic carotid and coronary artery diseases should undergo simultaneous carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG). A total of 624 papers were found using the reported search, of which 20 represent the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study results of these papers are tabulated. Previous cohort studies showed mixed results, while advocating for the necessity of a randomized controlled trial (RCT). A recent RCT showed that patients undergoing prophylactic or simultaneous CEA + CABG had lower rates of stroke (0%) compared with delayed CEA 1-3 months after CABG (7.7%), without significant perioperative mortality difference. This study included patients with unilateral severe (>70%) asymptomatic carotid stenosis requiring CABG. An earlier partly randomized trial also showed better outcomes for patients undergoing simultaneous procedures (P = 0.045). Interestingly, systematic reviews previously failed to show compelling evidence supporting prophylactic CEA. This could be partly due to the fact that these reviews collectively analyse different cohort qualities. Neurological studies have, however, shown reduced cognitive and phonetic quality and function in patients with unilateral and bilateral asymptomatic carotid artery stenosis. Twenty-one RCTs comparing lone carotid artery stenting (CAS) and CEA informed the American Heart Association guidelines, which declared CAS comparable with CEA for symptomatic and asymptomatic carotid stenosis (CS). However, the risk of death/stroke for CAS alone is double that for CEA alone in the acute phase following onset of symptoms, while CEA alone is associated with a doubled risk of myocardial infarction. There is, however, no significant difference for combined 30-day risk of death/stroke/myocardial infarction. Outcomes of hybrid or simultaneous CAS/CABG procedures show comparable results, albeit from rather small cohorts. While current evidence leans towards simultaneous CEA/CABG, the emergence of hybrid operating theatres in various institutions may allow larger cohorts with subsequent significant data on simultaneous CAS/CABG. A randomized controlled trial comparing both approaches would be crucial in informing future updates of existing guidelines.

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BackgroundDiffering perfusion of the left and right ventricular coronary territory may influence flow-profiles of saphenous vein grafts (SVGs). We compared flow parameters, measured by transit-time flowmetry (TTFM), in left- and right-sided SVGs during coronary artery by-pass grafting (CABG).MethodsRoutine TTFM measurements were obtained in 167 SVGs to the left territory (55%) and 134 SVGs to the right territory (total of 301 SVGs in 207 patients). The four standard TTFM parameters, [mean graft flow (MGF), pulsatility index (PI), percentage diastolic filling (%DF), and percentage backward flow (%BF)] were compared. Differences in flow parameters were also examined according to surgical technique (on- vs. off-pump).ResultsNo significant difference between coronary territories was found for MGF, PI and %BF. However, a higher %DF was noted in left-sided SVGs in the overall cohort as well as in the on-pump (both p < 0.001) and the off-pump cohorts (p = 0.07). Further, a significantly higher %BF was found in SVGs performed off-pump to the left territory (1.2 ± 2.5 vs. 2.3 ± 3.0, p = 0.023). In a multivariate regression analysis, anastomosing a SVG to the left territory was weakly associated with higher PI (OR = 0.36, p = 0.026) and strongly associated with higher %DF (OR = 5.1, p < 0.001). No significant association was found for MGF, PI, %DF or %BF in either the on-pump nor the off-pump cohorts.ConclusionsAlthough statistically significant, the established differences in TTFM parameters between left- and right-sided vein grafts were small and unlikely to be of clinical relevance.

clinicaltrials.gov identifier: NCT02511834.