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The left internal mammary artery (LIMA) is the gold standard conduit used to revascularize the left anterior descending artery and has consistently been shown to be associated with better survival, graft patency, and freedom from cardiac events compared with other used conduits. Evaluation of LIMA flow and anatomy is not routinely done by the interventional cardiologist while performing the left heart catheterization. We present a case where the LIMA was found to be the major blood supply to the left leg, which might have led to leg ischemia if the LIMA had been used as graft.

Endobronchial stenting is a well-established palliative approach in lung cancer patients with airway obstruction secondary to tumor burden. However endobronchial stenting can be complicated by stent erosion into adjacent vessels. Although most cases of endobronchial stent-related hemoptysis can be treated by stent revision and/or surgical resection, here we present a case managed by endovascular pulmonary arterial stent placement as a last resort option in the management of an iatrogenic bronchovascular fistula in a nonsurgical candidate.

This chapter discusses patient blood management strategies in cardiac surgery, including sections on the burden of anaemia in cardiac surgery, blood transfusion in cardiac surgery, patient blood management in cardiac surgery (management of anaemia, optimization of haemostasis, autotransfusion techniques, and other supportive measures), and outcomes of patient blood management programmes.

While the focus of this review is on preoperative anemia management, a modifiable risk factor and the cornerstone of PBM, the importance of other allogeneic components on adverse outcomes and the impact of the pandemic on their availability, especially platelets with their short shelf life, should not be minimized. The implementation of a multidisciplinary PBM program with an emphasis on meticulous surgical and perioperative hemostasis will contribute to decreased allogeneic component utilization with improved patient outcomes. Cardiac surgery PBM initiatives should include the identification of patients at high risk of bleeding, minimizing intraoperative hemodilution, maintaining normothermia, prevention of fibrinolysis, individual heparin/protamine titration, use of cell salvage, and perioperative treatment algorithms for bleeding patients.57 The COVID-19 epidemic created a dramatic shift in patient triage and in the use of surgical resources. The epidemic-related changes to blood supply, and transfusion needs offers multiple opportunities and challenges for transfusion decisions and for management of blood resources. Limited early experience suggests several features associated with blood resource management during the pandemic. Delays in timing of operations offers an ideal opportunity to improve coagulation parameters and optimize RBC levels. Improving preoperative patient profiles includes a multifaceted approach to risk assessment and careful triage. A preoperative anemia clinic can help in this process. The uncertain duration of this pandemic, and the likelihood of future pandemics, makes it necessary to implement pandemic-specific interventions that may not have robust evidence but are supported by short-term experience and observational data. These alternatives offer the best options for management until a larger more robust evidence base is accrued. Conflict of Interest Statement Dr Shander has received funding from Masimo, CSL Behring, Pharmacosmos, and Daiichi-Sankyo, which are unrelated to the submitted work but may contain relevant conflicts of interest. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Efforts to reduce blood product transfusions and adopt blood conservation strategies for infants and children undergoing cardiac surgical procedures are ongoing. Children typically receive red blood cell and coagulant blood products perioperatively for many reasons, including developmental alterations of their hemostatic system, and hemodilution and hypothermia with cardiopulmonary bypass that incites inflammation and coagulopathy and requires systemic anticoagulation. The complexity of their surgical procedures, complex cardiopulmonary interactions, and risk for inadequate oxygen delivery and postoperative bleeding further contribute to blood product utilization in this vulnerable population. Despite these challenges, safe conservative blood management practices spanning the pre-, intra-, and postoperative periods are being developed and are associated with reduced blood product transfusions. This review summarizes the available evidence regarding anemia management and blood transfusion practices in the perioperative care of these critically ill children. The evidence suggests that adoption of a comprehensive blood management approach decreases blood transfusions, but the impact on clinical outcomes is less well studied and represents an area that deserves further investigation.

Despite more than a half century of "safe" cardiopulmonary bypass (CPB), the evidence base surrounding the conduct of anticoagulation therapy for CPB has not been organized into a succinct guideline. For this and other reasons, there is enormous practice variability relating to the use and dosing of heparin, monitoring heparin anticoagulation, reversal of anticoagulation, and the use of alternative anticoagulants. To address this and other gaps, The Society of Thoracic Surgeons, the Society of Cardiovascular Anesthesiologists, and the American Society of Extracorporeal Technology developed an Evidence Based Workgroup. This was a group of interdisciplinary professionals gathered to summarize the evidence and create practice recommendations for various aspects of CPB. To date, anticoagulation practices in CPB have not been standardized in accordance with the evidence base. This clinical practice guideline was written with the intent to fill the evidence gap and to establish best practices in anticoagulation therapy for CPB using the available evidence. To identify relevant evidence, a systematic review was outlined and literature searches were conducted in PubMed using standardized medical subject heading (MeSH) terms from the National Library of Medicine list of search terms. Search dates were inclusive of January 2000 to December 2015. The search yielded 833 abstracts, which were reviewed by two independent reviewers. Once accepted into the full manuscript review stage, two members of the writing group evaluated each of 286 full papers for inclusion eligibility into the guideline document. Ninety-six manuscripts were included in the final review. In addition, 17 manuscripts published before 2000 were included to provide method, context, or additional supporting evidence for the recommendations as these papers were considered sentinel publications. Members of the writing group wrote and developed recommendations based on review of the articles obtained and achieved more than two thirds agreement on each recommendation. The quality of information for a given recommendation allowed assessment of the level of evidence as recommended by the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Recommendations were written in the three following areas: (1) heparin dosing and monitoring for initiation and maintenance of CPB; (2) heparin contraindications and heparin alternatives; and (3) reversal of anticoagulation during cardiac operations. It is hoped that this guideline will serve as a resource and will stimulate investigators to conduct more research and to expand on the evidence base on the topic of anticoagulation therapy for CPB.

Iliac arterial stenting is performed both in the operating room (OR) and the catheterization lab (CL). To date, no analysis has compared resource utilization between these locations.Consecutive patients (n = 105) treated at a single center were retrospectively analyzed. Patients included adults with chronic, symptomatic iliac artery stenosis with a minimum Rutherford classification (RC) of 3, treated with stents. Exclusion criteria were prior stenting, acute ischemia, or major concomitant procedures. Immediate and two-year outcomes were observed. Patient demographics, perioperative details, physician billings, and hospital costs were recorded. Multivariable regression was used to adjust costs by patient and perioperative cost drivers.Fifty-one procedures (49%) were performed in the OR and 54 (51%) in the CL. Mean age was 57, and 44% were female. Severe cases were more often performed in the OR (RC ≥ 4; 42% vs. 11%, P 0.001) and were associated with increased total costs (P 0.01). OR procedures more often utilized additional stents (stents ≥ 2; 61% vs. 46%, P = 0.214), thrombolysis (12% vs. 0%, P = 0.011), cut-down approach (8% vs. 0%, P = 0.052), and general anesthesia (80% vs. 0%, P 0.001): these were all associated with increased costs (P 0.05). After multivariable regression, location was not a predictor of procedure room or total costs but was associated with increased professional fees. Same-stay (5%) and post-discharge reintervention (33%) did not vary by location.The OR was associated with increased length of stay, more ICU admissions, and increased total costs. However, OR patients had more severe disease and therefore often required more aggressive intervention. After controlling for these differences, procedure venue per se was not associated with increased costs, but OR cases incurred increased professional fees due to dual-provider charges. Given the similar clinical results between venues, it seems reasonable to perform most stenting in the CL or utilize conscious sedation in the OR.