Study on relationships among deep vein thrombosis, homocysteine and related B group vitamins

Hyperhomocysteinemia has been considered as a potential risk factor for deep venous thrombosis [DVT] but it is still controversy. We aimed to evaluate the prevalence of hyperhomocysteinemia in patients with DVT. Our second objective was to document the prevalence of folate, Vitamin B6, and Vitamin B12 level in this patient population. Sixty patients with DVT aged from 23 to 84 years, were assessed regarding demographic characteristics, serum levels of homocysteine, folate, vitamin B12, and vitamin B6. The diagnosis of DVT was based upon Wells scoring system and serum D-dimer level and confirmed by deep venous Doppler ultrasonography of the lower limbs. Mean serum homocysteine levels were found significantly higher in patients over the age of 40 years [10.81 +/- 4.26 micromol/L vs 9.13 +/- 3.23 micromol/L]. Of all the patients, 9 patients had homocysteine level above the 15 micromol/L, 26 had folic acid level below 3 ng/ml, one had vitamin B12 level below 150 pmol/L, and two had vitamin B6 level below 30 nmol/L. In the hyperhomocysteinemic group, five patients had low folic acid level, one had low vitamin B12 level, and two had low vitamin B6 level. Hyperhomocysteinemia, in women older than 40 years, may be a risk factor for DVT. Folic acid deficiency may also influence serum homocysteine concentrations. Folate therapy may be offered to the patients with DVT. However further studies are required to clarify the underlying molecular mechanisms

Diagnostic value of the biochemical tests in patients with purulent pericarditis

Purulent pericarditis is a collection of purulent effusion in the pericardial space. It has become a rare entity with the increased availability and use of antibiotics. In contrast to pleural empyema, there are few data regarding the biochemical parameters of purulent pericardial effusion to aid diagnosis. Therefore, in this study, we have evaluated the diagnostic utility of biochemical tests in patients with purulent pericarditis. Between September 2004 and September 2012, we treated fifteen children with purulent pericarditis and tamponade. There were 8 boys and 7 girls, ranging in age from 8 months to 14 years, with a mean age of 5.3 +/- 3.2 years. Echocardiographic diagnosis of cardiac tamponade was made in all patients. All patients underwent immediate surgical drainage due to cardiac tamponade. The diagnosis of purulent pericarditis was supported by biochemical tests. Anterior mini-thoracotomy or subxiphoid approach was performed for surgical drainage. The most common clinical findings were tamponade, hepatomegaly, tachycardia, fever refractory antibiotic therapy, dyspnea, tachypnea, cough, and increased jugular venous pressure. Central venous pressure decreased and arterial tension increased immediately after the evacuation of purulent effusion during operation in all patients. The pericardial effusion had high lactic dehydrogenase, and low glucose concentration, confirming purulent pericarditis. Also, pH [mean +/- SD] was 7.01 +/- 0.06. The culture of pericardial effusions and blood samples were negative. Biochemical tests are useful guideline when assessing the pericardial effusions. However, these tests should be interpreted with the clinical and operative findings

Surgical management of iatrogenic vascular injuries

Iatrogenic vascular injury is an abnormal state that occurs in patients as a result of inadvertent or erroneous treatment by physicians or surgeons. We describe our 10 year experience with patients who underwent surgical repair of iatrogenic vascular injuries after catheterization or operation. Thirty one patients with iatrogenic vascular injury incurred between February 2001 and February 2011 who were surgically managed in our Department were reviewed retrospectively. The clinical presentation, localization and type of vascular injury were each analyzed. This study group consisted of 19 males and 12 females, ranging in age from 16 to 69 years with an average age of 47.8 years. Of the 31 iatrogenic vascular injuries, 19 resulted from a percutaneous procedure and 12 were sustained intraoperatively. The intraoperative iatrogenic injuries affected the inferior vena cava in three patients, left renal vein in one, external iliac artery in four, common carotid artery in three, and internal carotid artery in one. Eleven patients associated with catheterization were operated on immediately. The remaining eight were operated on an elective surgical basis [Pseudoaneurysm or arteriovenous fistula]. All patients made an uneventful recovery. Although experience and thorough knowledge of the vascular anatomy can prevent many potential iatrogenic vascular injuries, the risk of iatrogenic vascular injury cannot be completely eliminated. Therefore, we recommend that major operations requiring dissection in proximity to the vascular structures, and catheter based diagnostic or therapeutic procedures should be performed only in hospitals with an established vascular surgery department

Emergent surgical retrieval of an embolized septal occluder from the main pulmonary artery

Surgical closure of ASD has been used for over 50 years and appears to be a safe and effective operation. However, over the past decade, transcatheter closure techniques have been increasingly practiced. We present a case of 51 -year old woman with atrial septal defect [ASD]. She presented with progressive decrease in exercise tolerance. Echocardiographic examination-showed the ASD and a 26mm septal occluder device [Cardio-fix septal occluder] was successfully deployed under fluoroscopic and echocardiographic guidance. However, the patient suddenly complained of palpitation and sustained ventricular tachycardia thirty minutes after the procedure. A repeat echocardiographic examination confirmed embolization of the device into main pulmonary artery. Due to failure of capture of the device via multisnare, the patient was immediately taken to the operating room for removal of the device and surgical closure of the defect. The embolized device was grasped and retrieved from proximal pulmonary artery between index and middle fingers inserted into the main pulmonary artery via the tricuspid and pulmonary valves. The ASD was closed by running nonabsorbable polypropylene suture. Postoperative recovery was uneventful. The patient was discharged home after a total of six days of hospitalization

Surgical management of atrial septal defect in patients over 40 years of age

Atrial septal defect [ASD] makes up about 10% of all congenital heart diseases diagnosed after delivery and up to 30-40% of heart defects diagnosed in patients aged over 40 years. The objective of this study was to evaluate the effects of surgical ASD repair on functional status, right ventricular size, cardiothoracic ratio and pulmonary hypertension in patients over 40 years of age. Between the period of August 2001 and August 2010, 20 of the patients who had undergone surgical repair of a secundum ASD when they were aged >40 years at our institution were included in this study. To evaluate the effects of surgery on clinical outcome, we compared functional status, echocardiographic and radiographic findings of the patients before and after surgery. The defect was closed with either a running nonabsorbable suture or an autologous pericardial patch. Postoperatively, clinical status of the patients improved significantly. The mean NYHA functional class decreased from 2.8 +/- 0.4 to 1.5 +/- 1.1 [P < 0.001]. Postoperatively, mean right ventricle diameter was found regressed from 38.2 +/- 9.3 mm to 34.8 +/- 6.2 mm [P < 0.002] at a median interval of four months. The pulmonary artery pressures were also significantly decreased [p < 0.002]. The data provided by this study suggest that surgical repair of ASD improves functional status and relieves symptoms. Therefore, we suggest that ASDs that are unsuitable for transcatheter closure or requiring additional surgical intervention should undergo surgical repair to reduce subsequent morbidity and mortality, in patients including over 40 years of age

Our experience of infrapopliteal revascularization of lower extremity in ten years

In this study the long term results of infrapopliteal arterial revascularization procedure was evaluated. The efficiency of distal revascularization was also searched for the treatment of critical limb ischemia. From 1999 to 2009 32 patients underwent infrapopliteal revascularization procedure in our hospital for the treatment of critical limb ischemia. Demographic data of patients are: 23 male, 9 female and mean age was 60.5. Hypertension [n:15, 46.3%], diabetes mellitus [n:16, 50%], smoking [n:29, 90.6%] were the risk factors. The patients were classified in Fontaine III [n:25] and Fontaine IV [n:7]. Extremity viability and long term patency was detected with limb examination, Doppler Ultrasonography and angiography. The cases were evaluated for post operative mortality, morbidity and primary graft patency for one year. Mean follow up period was 21.3-/+15.9 monthes [12-60 monthes]. Two patients died in early post operative period. Eight patients underwent re-operation. Re-operations were performed on six patients for the treatment of acute graft thrombosis and two patients for the control of surgical bleeding. The long term graft patency was 38% and extremity recovery rate was 46%. In post operative early period two minor and one major amputation was performed. Infrapopliteal arterial revascularization procedure is an efficient method for the treatment of critical limb ischemia and high rate of long term patency is the main advantage of this procedure

Surgical repair of delayed chronic type A dissection after previous coronary artery bypass grafting

We report of a 57 years-old woman who had undergone coronary artery bypass three years previously. Computed tomography [CT] revealed that the ascending aorta was dilated to about 7cm in diameter, with type A dissection. Angiography revealed that left internal thoracic artery [LITA] graft to left anterior descending artery [LAD] and saphenous vein grafts to posterior descending artery [PDA] branch of the right coronary artery [RCA] and second obtuse marginal [OM] branch of the circumflex artery [CX] correspondingly were patent. Though the risk of surgical, treatment via repeat median sternotomy is usually very high in these cases, we successfully performed the reoperation using profound hypothermic circulatory arrest. We dissected the mediastinum by using a sternum retractor for ITA and saphenous vein grafts dissection. We didn't use cardioplegia during profound hypothermic circulation

Management of giant venous aneurysms secondary to arteriovenous fistula in hemodialysis patients

An aneurysmal fistula can continue to provide hemodialysis access for along time, but giant aneurysms should be operated on to prevent complication. The purpose of this study was to describe our experience of the surgical management of giant venous aneurysms that have developed as a complication of dialysis access. Twenty patients with giant venous aneurysms of the AVF underwent surgical procedures at our hospital from December 2003 to December 2010. The diagnoses were made by physical examination and Color Doppler Ultrasonography. There were 12 male and 8 female patients ranging in age from 29 to 68 years with a mean age of 44.6 +/- 12.3 years. Plication of the aneurysmal dilatations was performed in 17 patients. In two patients, aneurysmal dilatations were excised with restoration of the artery. The remaining one patient who received a successful renal transplantation was also associated with brachial artery aneurysm. Venous aneurysmal dilatations were excised and arterial aneurysms were repaired. All patients experienced a marked decrease in the size of venous dilatations. There were no vascular complications during the follow-up period. We suggest that plication is safe and effective in controlling venous dilatation and achieving patency. Reinforcing the suture line using an external mesh may not be required. However, prospective randomized studies will be required to assess the long-term outcomes

Management of combined femoral artery and vein injuries

The aim of this study was to review our experience with combined injuries to the femoral artery and vein, and to analyze the role of venous repair. Thirty two patients with penetrating injuries of the both femoral artery and vein underwent surgical management at our hospital from May 1999 to August 2009. Primary vascular repair was carried out whenever possible; if not possible the interposition graft was used. This study group consisted of 27 males and 5 females, ranging in age from 15 to 72 years with a mean age of 28.3 years. The mechanism of injury included gunshot wounds in 18 patients and stab wounds in 14 patients. Primary arterial repair was performed in 17 patients. Autogenous saphenous vein graft was used in nine patients and vein patch in two patients. Polytetraflouroethylene [PTFE] graft was used in four patients. All patients had associated venous injuries of which 24 patients had primary venous repair, five had vein graft interposition, and two had PTFE graft interposition. Seven patients had fasciotomies. Graft thrombosis occurred in three arterial repairs. Above-knee amputation was required in two patients with femur fracture. Patients with combined femoral artery and vein injuries can be managed successfully with clinical assessment alone. In these dual vascular injuries, both the femoral artery and vein injuries should be repaired to avoid complications. If venous ligation becomes compulsory, adjuvant therapies and techniques should be recommended such as the use of fasciotomy, anticoagulation treatment, elevation of the lower limb and compression stockings

Management of penetrating heart and accompanying lung injuries

Penetrating heart injury is potentially a life threatening condition due to cardiac tamponade or exsanguinating hemorrhage. The aim of this study was to evaluate victims who were referred to our hospital with penetrating heart and accompanying lung injuries and to review our overall outcome with this type of combined injuries. Twenty patients with combined penetrating heart and lung injuries were operated at Yuzuncu Yil University Research Hospital, between May 1999 and January 2010. The diagnosis of combined heart and lung injuries was proved by surgical exploration in all cases. The surgical procedures mainly included the relief of cardiac tamponade, control of bleeding, repair of cardiac and pulmonary lacerations, and coronary artery bypass grafting if required. In this series of 20 patients; there were 18 males and two females between the age of 14 to 60 years, with a mean age of 34.8 +/- 13.5 years. Seventeen victims sustained stab wounds, and the remaining three were injured by a gunshot wounds. In 20 patients there were 22 cardiac chamber injuries. The most commonly injured cardiac chamber was the right ventricle followed by the left ventricle. In addition to the injuries to heart muscle, injuries to the coronary arteries were found in two patients. The most commonly injured lung lobe was the left upper lobe. Our experience shows that early diagnosis and immediate surgical intervention are the main factors affecting patient survival after penetrating heart and lung injuries. Therefore, heart injury should always be kept in mind in victims with penetrating thoracic injuries

Renal cell carcinoma extending into the inferior caval vein: report of two cases

Renal cell carcinoma [RCC] is rare neoplasm and rarely extends to IVC. Perinephric and venous system invasion is an important prognostic sign for RCC. The tumor may grow intraluminally into the renal vein and Inferior Vena Cava [IVC] as an extension of primary tumor. In this report, we present two unusual case of venous system involvement, invasion of RCC into SVC. RCC with tumor thrombus extension into the IVC remains a difficult operative challenge. However surgical intervention should be performed. Our cases were successfully operated and their post operative recovery was uneventful

Spontaneous coronary artery dissection associated with apical hypertrophic cardiomyopathy

Apical hypertrophic cardiomyopathy [HCM] is a relatively uncommon inherited disease. Spontaneous coronary artery dissection [SCAD] is also uncommonly observed, which often occurs in pregnant or post partum women but is rare in men. This report describes a 38 years old man with apical hypertrophic cardiomyopathy who developed SCAD leading to acute inferior myocardial infarction. After emergent appendectomy operation at another hospital, he was immediately transferred to the Cardiology Department of our hospital due to acute myocardial infarction. He emergently underwent coronary angiography which showed a long dissection involving the right coronary. He underwent an emergent CABG with cardiopulmonary bypass. Postoperative recovery was uneventful and he was discharged. According to our knowledge, no case of spontaneous coronary artery dissection associated with apical hypertrophic cardiomyopathy unrelated to postpartum period or oral contraceptive use has been reported so far

Management of constrictive pericarditis: a comparative study between median sternotomy and left thoracotomy

Constrictive pericarditis [CP] requires pericardiectomy but the choice of surgical approach remains controversial. Hence we have reviewed our experience of pericardiectomy carried out for CP and compared the results of pericardiectomy performed by median sternotomy versus left thoracotomy with regard to functional outcomes. The study group consisted of 33 patients with CP who underwent pericardiectomy from May 1999 to January 2010 at our institution. There were 22 female and 11 male patients, ranging in age from 5 to 57 years with a mean age of 45 years. Pericardiectomy was performed via median sternotomy in 17 patients [Group A]. In the remaining 16 patients [Group B], pericardiectomy was performed via a left anterolateral thoracotomy in the fifth intercostal space. During the subsequent follow-up, both groups of patients showed a similar and significant improvement in New York Heart Association [NYHA] functional class. In the group A, the mean NYHA functional class decreased from 3.3 +/- 0.7 to 1.8 +/- 0.5 [P = 0.0004]. In group B, the mean functional class decreased from 3.2 +/- 0.9 to 1.6 +/- 0.6 [P = 0.00005]. Also, both groups had a similar and significant improvement in their mean CVP. In the group A, the mean central venous pressure [CVP] decreased from 15.2 +/- 3.1 mmHg to 8.3 +/- 3.2 mmHg [P<0.005]. In the group B, the mean CVP decreased from 15.1 +/- 4.9 mmHg to 7.7 +/- 2.4 mmHg [P<0.004]. Constrictive physiopathology is a problem primarily of the ventricles and can be alleviated by decorticating both the right and left ventricles. Therefore, CP could be relieved through the left thoracotomy or median sternotomy in most cases. However, echocardiographic findings should be considered to prefer thoracotomy or sternotomy approach

comparison between minilaparotomy and conventional approach for the surgical therapy of aortailiac occlusive disease

To search for less traumatizing measures for Aortic Occlusive Disease [AOD] surgeries to improve the recovery from surgery. Another objective was comparison of retroperitoneal minilaparotomy [RML] with conventional transperitoneal classic median laparotomy [TCML] with respect to per-operative and post-operative outcome and complications. It was a retrospective comparative study. All patients undergoing AOD surgery were enrolled. Our comparative data of 20 patients who had AOD surgery by TCML [TCML group] performed from January 2003 to December 2006 and 20 cases of patients who had AOD surgery by RML [RLM group] performed from January 2006 to December 2009 is presented. Chi-square and Fischer test with significance of p value being taken at 0.05 were used for categorical data, while student's t test was used for continuous data. Mean age, gender, the operation and aortic occlusion time was similar between the TCML and RLM groups. The length of stay in the intensive care unit [ICU] and total hospital stay in the RLM group was statistically shorter compared to the TCML group[p<0.05]. Major complications were rare in both the groups. During AOD surgery, RLM appears to be an attractive alternative to traditional TCLM with fewer complications

Management of traumatic brachial artery injuries: a report on 49 patients

The brachial artery is the most frequently injured artery in the upper extremity due to its vulnerability. The purpose of our study was to review our experience with brachial artery injuries over a 9-year period, describing the type of injury, surgical procedures, complications, and associated injuries. Forty-nine patients with brachial artery injury underwent surgical repair procedures at our hospital, from the beginning of May 1999 to the end of June 2008. The brachial artery injuries were diagnosed by physical examination and Doppler ultrasonography. Depending on the mode of presentation, patients were either taken immediately to the operating room for bleeding control and vascular repair or were assessed by preoperative duplex ultrasonography. This study group consisted of 43 males and 6 females, ranging in age from 6 to 65 years with a mean [SD] age of 27.9 [6.7] years. The mechanism of trauma was penetrating in 45 patients and blunt in the remaining 4 patients. Stab injury was the most frequent form of penetrating trauma [24 of 45]. Treatment included primary arterial repair in 5 cases, end-to-end anastomosis in 28 cases, interposition vein graft in 15 cases, and interposition-ringed polytetrafluoroethylene graft in 1 case. Associated injuries were common and included venous injury [14], bone fracture [5], and peripheral nerve injury [11]. Fifteen patients developed postoperative complications. One patient underwent an above-elbow amputation. Prompt and appropriate management of the brachial artery injuries, attention to associated injuries, and a readiness to revise the vascular repair early in the event of failure will maximize patient survival and upper extremity salvage

Echinococcal tension pneumothorax in a pregnant woman

Pulmonary hydatid cyst in pregnancy is a very rare pathology and its diagnosis and treatment is stilt a complex of problem. We report a rare case of ruptured giant pulmonary hydatid cyst presenting with tension pneumothorax during pregnancy. According to our knowledge this is the first report of such a case. A 21 -year old pregnant woman was admitted to our hospital with complaints of left-sided chest pain, cyanosis and dyspnea. Chest radiograph showed tension pneumothorax, mediastinal shift, and tracheal displacement. Echocardiography revealed perforated hydatid cyst adjacent to pericardium. She was taken to the operating room immediately. During operation, a giant perforated hydatid cyst [12x10cm] was found, outside the pericardium displacing and compressing the left lower lobe. Histopathological examination confirmed the diagnosis. Approximately 5 months later she had a spontaneous vaginal delivery. Both the patient and her baby were healthy. Perforated pulmonary hydatid cyst should be kept in mind in the differential diagnosis of tension pneumothorax in a pregnant woman and surgical intervention should be performed promptly

Management of penetrating superior caval vein injury

Penetrating injuries to the superior caval vein [SCV] are rare but are very serious. They can be associated with hemodynamic instability and often produce a substantial technical challenge to the surgeons. We report a case of 32-year old man who was admitted to our hospital having sustained multiple stab wounds over the right chest wall and extremities. Many victims of penetrating thoracic trauma with SCV injury are in profound shock, whereas our patient on arrival in the emergency department had a stable condition, so the diagnosis was delayed. We consider that associated mediastinal pleural adhesions confined the bleeding into the mediastinum which prevented prompt massive bleeding. Therefore he tolerated a preoperative delay of six hours. Caval injury should be kept in mind in the differential diagnosis of hemothorax

Management of primary venous aneurysms

Venous aneurysms are a relatively rare abnormality. Unlike arterial aneurysms, venous aneurysms are a much less frequent abnormality. The purpose of our study was to review our experience in the management of venous aneurysms. Nine patients with venous aneurysms, who had undergone operation in the Department of Cardiovascular Surgery, Yuzuncu Yil University Medical School, Van, Turkey, during the period September 1997 through to May 2003, were included in this study. There were 5 female and 4 male patients, ranging in age from 16-47-years with a mean age of 31 +/- 7 years. They were diagnosed by color flow duplex imaging. Eight patients had saccular aneurysm; the remaining one patient with basilar vein aneurysm, had fusiform aneurysm. Aneurysms were located the lower extremities in 4 cases, the upper extremity in 4, and external jugular vein in one. Aneurysms size ranged from 2, 3 to 5, 5 cm [mean 3, 6 cm]. There were no symptoms in 2 patients [cephalic vein aneurysm in one patient, short saphenous vein aneurysm in one]. These patients were operated on for cosmetic purposes. Six patients complained of pain associated with a subcutaneous swelling. The remaining one patient with popliteal vein aneurysm complained of extremity pain, associated with deep venous thrombosis. All patients underwent surgery under local anesthesia. In 7 patients, aneurysms were resected and venous continuity with a graft was found unnecessary. End to end anastomosis was performed in 2 patients [popliteal vein aneurysm in one and axillary vein aneurysm in one]. During follow up period, there were no recurrences. Venous aneurysms may cause thrombophlebitis, thrombus formation, pulmonary embolism and theoretical complication of spontaneous rupture. Varicose veins, hemangiomas, lymphocele, hernias, hygromas, arteriovenous fistulas and similar subcutaneous swellings located subcutaneous venous spaces should be considered in the differential diagnosis. Consequently, we suggest that surgical treatment be performed to prevent subsequent complications in all cases