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22.7
Transplantation of kidneys from very young pediatric donors into adult recipients is associated with
excellent outcome
T. Wolff, F. Burkhalter, T. Eugster, C. Rouden, J. Steiger, L. Gürke (Basel)
Objective: The kidneys from very small donors are still often not used for transplantation into adult
recipients because of the fear of technical complications, thrombosis and poor outcome due to insufficient
renal mass.
Methods: We report the retrospective analysis of all our kidney transplants into adult recipients with
kidneys from donors younger than 3 years, performed from 2004 to 2009.
Results: We performed 20 transplants with donors younger than 3 years, which corresponds to 12% of
the cadaveric kidney transplant performed during the period of observation. Median donor age was 18
months (range 5 -34 months), median donor weight was 11.5 kg (range 7.8 - 15.0 kg). Median recipient
age was 49y (range 22-72y), median recipient weight was 64 kg (range 40 - 94 kg). In 18 cases
the kidneys had been harvested in hospitals outside Switzerland and the organs had been refused
from all the tranplant centres in the country of origin. In 3 recipients two kidneys were transplanted en
bloc, the remainder were single kidney transplants. All kidneys were implanted in standard technique
in the iliac fossa with anastomosis to the iliac vessels. In 3 cases additional surgical measures such as
separate implantation of a lower pole artery or extension of a short renal vein with saphenous vein was
required. Primary non function of the graft occurred in 2 patients (10%), once because of thrombosis
of en bloc kidneys, once because of hyperacute rejection. All the remaining grafts are functioning at
present, median follow-up being 2y (range 0.3 - 5.9y). Median creatinine clearance one year after
transplantation was 60 ml/min (range 30 - 110). Both one year graft survival and creatinine clearance
compare favorably with recipients of cadaveric adult kidneys during the same period. No cases of
transplant vessel stenosis occurred during the follow-up. The graph below shows that in contrast to
adult grafts, renal function actually continues to improve for several years.
Conclusion: Our results show that transplantation of kidneys from donors younger than 3y is associated
with a one year graft survival of 90% and very good longterm graft function. The high rate of
organs from outside Switzerland is evidence of the unwillingness of most transplant centres to use
organs from very small donors. Our results suggest that this attitude is not justified.
22.8
Introduction of a totally implantable venous access system (TIVAS/Port-à-Cath) through jugular
access is feasible and safe
P.-A. Wandeler, A. Meyer, M. Menth, B. Egger (Fribourg)
Objective: The TIVAS or Port-à-Cath-System is installed for long term chemotherapy or nutritional requirements.
The commonest site is the cephalic vein, because of the low associated morbidity. Sometimes
this venous access is unusable and a secure alternative, such as a jugular access, must be
found.
Methods: We analysed prospectively 9 patients with a TIVAS installed by internal or external jugular
vein access, between July 2007 and October 2009 (28 months). During the same period, we implanted
529 TIVAS by cephalic access or direct puncture of the subclavian vein. We recorded data of
reoperation, device’s dysfunction, occlusion and infection rates.
Results: In our patients collective, the reasons for conversion (n=9) were: The cephalic vein was not
found (n=4); it was too small (n=2); it was thrombosed (n=1); the catheter went in the vena axillaris
(n=1) and a stent put in the vena cava superior barred the conventional access to the subclavian vein
(n=1). In this special case, a puncture of the subclavian vein was intended twice without success.
The catheter was introduced in local anesthesia, five times into vena jugularis interna (VJI) and four
times into vena jugularis externa (VJE) with a purse string suture on the anterior wall. In eight patients,
no morbidity or dysfunctions were observed in the follow-up (17.1 months [6-28]). In one patient, we
noted a technical error with kinking of the catheter at the entrance of VJI. This problem was resolved by
reoperation in local anesthesia without changing the reservoir.
Conclusion: In rare cases, the vena cephalica is not usable for a venous access. To avoid the risk of
direct puncture of the vena subclavia in selected cases (COPD, antiaggregatory or crasis disorder), we
recommend to choose the internal or external jugular vein access. This technique is reproducible, safe
and not associated with higher morbidity than in systems with cephalic vein access.
22.9
Endovenous laser ablation of varicose veins: influence of laser power on the occlusion rate
D. P. Buchmann, J. Knaus, P. Nussbaumer (Lachen)
Objective: Ligation of the saphenofemoral junction (SFJ) and stripping of the vein is still considered the
gold standard in the treatment of varicose veins. Recent studies however report recurrence rates up
to 50% despite correct surgical technique. Today, alternative treatment options such as endovenous
laser treatment (EVLT) are well established and provide mid-term results comparable to open surgery.
However, currently there is no consensus concerning the different laser parameters. The goal of this
prospective study was to determine a standardized treatment for the great saphenous vein (GSV).
Methods: All treatments were performed using a laser fiber with a wavelength of 980nm. For the GSV
100J/cm power was applied continuously from the SFJ down to the distal thigh, subsequently 80J/cm
to the distal level of insufficiency or infragenicular. Follow up included clinical and duplex ultrasound
examinations 1 day, 6 weeks and 12 months postoperatively. The rate of occlusion was determined
and complications were documented. From 10/06 to 02/08 we treated 70 veins in 52 patients (16
male; mean age 49(22-79) years (group 1)) with a laser power of 12 W. After an interim analysis, we
decreased the laser power to 10 W, keeping all other parameters identical. From 02/08 to 11/09 we
treated 59 veins in 42 patients (16 male; mean age 42(23-69) years (group 2).
Results: Six weeks postoperatively the occlusion rate for group 1 was 77.3% vs. 97.3% for group 2
(p=0.004). At 12 months follow up the corresponding rates were 71% vs. 88.9%. To date 4 patients
(5.7%) from group 1 were reoperated on. The complication rate for group 1 was 35.7%: deep vein
thrombosis (1x), hyperpigmentations (8x), thrombophlebitis (1x), transient paraesthesia (15x). Complications
were seen in 8.5% in group 2: transient paraesthesia (3x), thrombophlebitis (1x), delayed
wound healing after ligation of perforator vein (1x). Group 2 showed significantly less (p