Fracture and atypical migration of an implantable central venous access device.

Distal embolization of a fractured indwelling central catheter is a rare complication. The pinch-off syndrome (POS) should be known, prevented and early detected. We present a case in which further radiological exams were required to find the fragmented catheter with an atypical migration, requiring local surgery for removing. After chest and abdominal CT scan, neck X-ray, and heart echography, the catheter was found on the lower limbs X-ray on the internal side of right knee corresponding to a location of saphenous vein. Implanted catheters should be removed after completion of treatment and the integrity of the system should be monitored. To avoid POS, a catheter must be inserted into the subclavian vein as laterally as possible.

Traumatic bilateral dissections of the internal carotid artery: an infrequent diagnosis not to be missed.

We report the case of two patients involved in a car crash and victims of multiple injuries. The diagnosis of bilateral dissection of the internal carotid arteries was only evoked belatedly in view of the increase of the neurologic symptoms. They benefitted from anticoagulant treatment. The clinical evolution was good. Dissection of both carotid arteries from blunt head or neck trauma has been reported but is unusual. Diagnosis and treatment are discussed.

Patent ductus arteriosus ligation: the LigaSure system may be unreliable.

Surgical ligation of a patent ductus arteriosus (PDA) in small premature infants may be performed with open thoracotomy or video-assisted thoracoscopic surgery (VATS). The LigaSure vessel sealing system (Valleylab/Tyco Healthcare, Boulder, CO) is increasingly being used because of its effectiveness in promoting coagulation. Moreover, for PDA ligation using VATS, the LigaSure system seems more practical than vascular clips. Among 81 children, including 43 premature infants weighing less than 1000 grams operated on for PDA in our institution, one 9-month-old boy weighing 7600 grams underwent PDA ligation using a LigaSure grasp. The perioperative aspect of the closed ductus was satisfactory. The following day, however, ultrasound control revealed recanalization of the ductus, and the child had to undergo a second operation. At operation, the ductus wall adventia and media appeared to have retracted to both extremities, leaving the intima exposed and pulsating under the blood pressure. The PDA ligation was repeated, but in conditions of severe hemorrhage. The LigaSure system works by fusing collagen in the tissue. However, because the ductus wall has less collagen than any other vessels in the body, the LigaSure vessel sealing system is not reliable for PDA ligation.

In high-risk patients, combination of antiinflammatory procedures during cardiopulmonary bypass can reduce incidences of inflammation and oxidative stress.

Previous studies showed that cardiopulmonary bypass (CPB) was directly associated with a global activation of the inflammatory response, production of oxygen free radicals, and signs of myocardial injury. We therefore evaluated, in the weakest patients, the biological and clinical benefits of a therapeutic optimization of CPB through the combination of several antiinflammatory procedures. High-risk patients undergoing cardiac surgery under CPB were included in this prospective randomized study. Control patients (n = 14) underwent conventional CPB, and treated patients (n = 13) underwent a CPB with Baxter Duraflo II heparin-coated circuits, high doses of aprotinin, and pre-CPB hemofiltration. Usual clinical hemodynamic and biological criteria, inflammation, and oxidative stress markers were measured before, during, and to the second postoperative day. Free radicals were quantified using electronic spin resonance spectroscopy with a spin trap. Significantly lower concentrations of C-reactive protein, interleukin-6, creatine kinase-MB, I-troponin, lactic acid, and systemic free radicals were observed in the plasma of treated patients. These patients had a reduction of postoperative complications and of the length of stay in the intensive care unit. Therefore, pre-CPB therapeutic optimization can reduce the inflammatory response, lower the level of oxidative stress, and help to ameliorate clinical outcome in high-risk patients.