Short series of upper limb acute arterial occlusions in 4 different etiologies and review of literature.

Upper limb acute arterial occlusions are uncommon, and when compared with lower limb occlusions, only a few cases have been reported. Although atrial fibrillation is the most common cause, many conditions may lead to ischemia. In this article, 8 cases of upper limb arterial ischemia due to 4 different etiologies were reported (7 brachial, 1 axillary), and the literature was reviewed.

Carotid endarterectomy performed after carotid artery restenosis following stent migration.

Right carotid occlusion and left carotid stenosis were determined in a patient who had undergone a cerebrovascular accident. We performed a carotid endarterectomy for the high-risk patient who developed middle cerebral artery occlusion during stenting and a restenosis owing to stent migration.

The determination of matrix metalloproteinase 9 activity and gene expression levels in Behcet's disease patients with aneurysmal complications.

The information concerning aneurysmal progress in Behcet's disease is still insufficient, while researches in the role of matrix metalloproteinases (MMPs) in aneurysmal formation are rapidly expanding. The goal of the present study is to investigate the role of metalloproteinase 9 (MMP-9) in vascular complications which is observed in 10% of Behcet's disease patients. Three groups have been studied; patients with Behcet's disease, patients with Behcet's disease who have vascular problems (vasculo-Behcet's), and patients with abdominal aortic aneurysm (AAA). The third group was used as a control. The activity and gene expression levels of MMP-9 in plasma have been determined. We showed that compared to AAA patients there was no difference in the MMP-9 activity in Behcet's disease patients (vascular and non-vascular). We also evaluated the gene expression level and activity of MMP-9 for every patient. The increase in the gene expression level for MMP-9 could only be detected at two patients. One of them was Behcet's, the other was AAA patient. It is surprising that MMP levels of these patients were different. While the patient with Behcet's had low protein level, another patient with AAA had high of MMP-9 level. This result suggested to us that the relationship between gene expression and active protein level is not correlated. It is not sufficient alone to determine MMPs levels for evaluating the pathogenesis. At the same time gene expression and the level of active protein should be assessed together.

Is female gender really a risk factor for carotid endarterectomy?

BACKGROUND: The aim of this study was to assess the effect of gender on mortality and morbidity in carotid endarterectomy (CEA) patients. METHODS: Forty-one female and 150 male patients who underwent isolated CEA operations, between 1994 and 2007, were included in this study. To find the role of gender in isolated CEA operations, patients with a previous history of cardiac operations, coronary interventions, and a staged cardiac and/or vascular operation were excluded from the study. RESULTS: In the postoperative period, one female patient (2.4%) and 8 male patients (4.9%) had neurological complications (p > 0.05). Hospital mortality rates of female and male groups were 0.0% and 2.4%, respectively (p > 0.05). Perioperative events which cause significant increase in hospital mortality were myocardial ischemia, low cardiac output, and need of intra-aortic balloon pump (p = 0.0001). Late mortality rates of female and male groups were 7.5% and 9.9%, respectively. The actuarial survival rate was 82.2 +/- 11.6% in women and 71.5 +/- 7.5% in men for a mean period of 36.4 +/- 29.1 months (p > 0.05). All the observed mortalities in the long term were cardiac-related or with other causes, no neurological deaths observed in both groups (p > 0.05). According to logistic regression analysis smoking and peripheral arterial disease were found as statistically significant risk factors for late mortality. CONCLUSION: Female gender is not a risk factor for stroke or death after CEA. Women should not be excluded from the benefits of CEA and gender should not be a consideration in the decision to perform it.

Secondary aortoenteric fistula in Behçet's disease.

Vascular manifestations of Behçet's disease include venous and arterial occlusions, arterial aneurysm and pseudo-aneurysm formation. The main problem of the surgical treatment of vascular lesions in Behçet's disease is the high incidence of complications such as recurrent aneurysms, thrombosis and fistulization to the adjacent organs. Here we present a case of Behçet's disease with multiple complications after aortic reconstructive surgery, including perigraft infection, abscess distal to the graft, occlusion of arteries of the lower extremities, aortoenteric fistula and distal anastomotic site aneurysm rupture.

Internal thoracic artery-inferior epigastric artery as a collateral pathway in aortoiliac occlusive disease.

OBJECTIVE: In patients with aortoiliac occlusion, the internal thoracic artery-inferior epigastric artery (ITA-IEA) collateral is one of the collaterals supplying blood flow to the lower extremity, and the interruption of this collateral may cause severe leg ischemia. The aim of this study was to evaluate by color duplex ultrasonography scans the ITA-IEA pathway and its significance as a collateral in providing lower-extremity perfusion in aortoiliac occlusive disease. METHODS: Color duplex ultrasonography scans were prospectively performed in 64 consecutive patients with aortoiliac occlusion. Blood flow measurement in the ITA, IEA, and common femoral artery was done on both sides. The patients were stratified according to occlusion level (aorta, common iliac artery, external iliac artery), and the data obtained from such groups were compared. RESULTS: In 95% of patients with aortoiliac occlusion, the ITA-IEA pathway was functioning as a collateral, with mean collateral flow of 66 +/- 48 mL/min, and its average contribution to lower-extremity perfusion was 38% +/- 23%. Additionally, a moderately positive correlation was found between flows of ITA and IEA (r = 0.55, P < .0001). Depending on the level of occlusion, the collateral flow and its contribution to perfusion progressively decreased from the proximal to distal aortoiliac occlusion level. Furthermore, the difference in the ITA-IEA flow volume was statistically significant between occlusion levels (P = .009), but the differences in the perfusion contribution were not different among levels (P = .311). There was also no statistical difference between the groups concerning collateral flow volume and contribution to lower-extremity perfusion in relation to unilateral or bilateral occlusion of the iliac artery, the state of distal run-off being good or poor, or the clinical findings being mild or severe. CONCLUSION: In patients with aortoiliac occlusion, the ITA-IEA collateral pathway is an important route providing lower-extremity perfusion. Additionally, Doppler sonographic flow measurements of the contribution of the ITA-IEA route to lower-extremity perfusion may provide beneficial diagnostic information necessary for the pretreatment work-up of patients with aortoiliac occlusion, especially for whom the ITA is planned to be used as a coronary artery graft.

Compelling nature of arterial manifestations in Behcet disease.

INTRODUCTION: We present our experience with surgical treatment of arterial complications in Behcet disease (vasculo-Behcet disease), and the long-term results and pitfalls of surgical treatment. MATERIAL AND METHODS: Between January 1990 and January 2003, 20 consecutive patients underwent surgery to treat vasculo-Behcet disease. Most patients (17 of 20) were men, with mean age of 38.4 years. RESULTS: Thirty-four operations were performed in 20 patients. The operative mortality rate was 5.8% (2 patients). There were 17 emergency operations, 6 because of ruptured primary abdominal aneurysms. There were five others with critical limb ischemia, resulting in 3 amputations. All patients were followed up postoperatively on average for 44 months (range, 6 months-14 years). Two additional patients were lost to follow-up. After the initial operation 10-year survival rate was 30%, 10-year complication-free survival rate was 13%, and 5-year repeat operation-free survival rate was 26%. CONCLUSION: Although surgical intervention should be postponed until active inflammation has subsided, often this is not possible, because of the emergent nature of these problems. Most arterial complications of vasculo-Behcet disease present with a pseudoaneurysm rupture or with impending rupture. An aggressive surgical approach can be life-saving in such instances, and should be undertaken regardless of long-term complications, which are more common when the operation is performed in the presence of active inflammation. Early and late results can be improved by individualizing, selecting a disease-free area for reconstruction, and eliminating use of autologous graft material.

Risk factors for stroke following coronary artery bypass operations.

BACKGROUND: Although the overall complication rates have been decreased significantly in recent years, stroke rates still remain high in patients undergoing coronary bypass operations. This study is designed to evaluate the risk factors for stroke in patients who had undergone coronary artery bypass surgery in an 8-year period in our clinic. METHODS: Between 1995 and 2003, 8547 coronary artery operations under cardiopulmonary bypass were performed. Retrospective analysis of the patient files revealed that 75 (0.9%) patients had stroke in the early postoperative period. RESULTS: Mean age of these patients was 62.3 +/- 9.5 years, and 54 (72%) were males. Stroke rate was 1.2% between 1995 and 1998 and this was significantly higher from the stroke rate (0.7%) of the period 1998 to 2003 (p = 0.03). Major technical differences between these two periods were the routine application of preoperative carotid arteries Doppler evaluation and intraoperative epiaortic echocardiography after 1998. Higher age (p = 0.000), female sex (p = 0.005), smoking (p = 0.03), presence of diabetes mellitus (p = 0.01), hypertension (p = 0.008), and left main coronary artery disease (p = 0.001), carotid surgery (p = 0.000), and peripheral vascular disease (p = 0.049) were identified as important risk factors in univariate analysis for stroke development. Higher age (p = 0.000; OR = 21.38), left main coronary artery disease (p = 0.007; OR = 7.26), peripheral vascular disease (p = 0.050; OR = 3.08), and operation date before 1998 (p = 0.012; OR = 6.33) were identified as important risk factors in logistic regression analysis. According to intraoperative epiaortic ultrasonography, operative strategy was changed in 9% of patients. Thirty-seven (49.3%) of the stroke patients died. Female sex (p = 0.023; OR = 5.18) and preoperative hypertension (p = 0.045; OR = 4.03) were observed as significant risk factors for mortality after stroke. CONCLUSION: Development of stroke is one of the major reasons of mortality after coronary artery bypass operations. It is essential to take all the measures to prevent this complication, especially in patients with known risk factors. Evaluation of carotid arteries prior to operation and application of routine intraoperative epiaortic echocardiography may in part eliminate stroke.

Acute gastrointestinal bleeding due to primary aortoduodenal fistula: report of two rare cases.

Primary aortoduodenal fistulas are among the rare causes of gastrointestinal hemorrhage and are defined as communications between the native abdominal aorta and the duodenum. The mortality rate is very high if undiagnosed and untreated. Two male patients, 61- and 76-years-old, were admitted to the emergency unit at different times with the chief complaints of abdominal pain, gastrointestinal hemorrhage and pulsatile mass in their abdomen. The first case experienced sudden massive upper gastrointestinal bleeding while being prepared for an emergency operation in the intensive care unit, and cardiac arrest developed within a few minutes. After resuscitation and successful surgical operation, the patient woke up without any neurological defect or sequelae and was extubated at the 9th postoperative hour. The second patient, who had been wounded by gun shot 30 years previously was admitted to the hospital because of simple gastrointestinal hemorrhage. A para-aortic pseudo-aneurysm connected with the duodenum was diagnosed by computed tomography. After successful surgical operation, the patient was discharged. In this report, a case of ruptured primary aortic aneurysm and another case of para-aortic pseudo-aneurysm connected with the duodenum, both of which were treated successfully by surgical operation, are presented.

Use of axillary artery to maintain cerebral perfusion in a patient requiring reconstruction of the brachiocephalic trunk and coronary arteries: technical note.

Our patient had 80% stenosis of the brachiocephalic artery and total occlusion of the left carotid and left subclavian arteries. Ascending aorta to brachiocephalic artery bypass grafting was performed, with a 10 mm Dacron graft. The right axillary artery was cannulated, and during construction of the distal anastomosis cerebral blood flow was from the right axillary artery. We believe this technique may be beneficial in surgery on an artery in which cerebral blood flow depends exclusively.