A novel troubleshooting technique for below-the-knee artery occlusions with proximal cap ambiguity: Transpedal Retrograde Wire Just Marker Technique.

BACKGROUND: Chronic total occlusions with ambiguous proximal caps pose a challenging problem in below-the-knee artery endovascular interventions. CASE REPORT: We defined a new technique for antegrade puncture and penetration of an ambiguous proximal cap in a 52-year old male patient with a non-healing wound on his right forefoot. Anterior tibial artery (ATA) was determined as the target vessel; however, its origin and course could not be determined. A retrograde guidewire (Asahi Gladius 0.018 inch, Asahi Intecc) was advanced into the distal ATA via transpedal loop following pedal loop angioplasty. This guidewire was advanced through and parked to the tibioperoneal trunk with a small distal loop at the tip. While the looped wire was held in its position as a marker for ATA ostium, a second guidewire (Asahi Gladius 0.018 inch, Asahi Intecc) with the guidance of 4F vertebral catheter (Vert Catheter, Merit Medical) successfully penetrated the ambiguous cap and subsequent target vessel revascularization was achieved with 2.5/150 mm peripheral balloon angioplasty catheter (Minerva SC 0.018 inch, BrosMed Medical). CONCLUSION: Transpedal Retrograde Wire Just Marker Technique is a novel and practical technique which can be used in chronic total occlusions of below-the-knee arteries with ambiguous proximal caps.

Comparison of Ultrasound-Guided Popliteal Sciatic Block Properties in Diabetic and Nondiabetic Patients.

BACKGROUND: We aim to share our popliteal sciatic nerve block (PSB) experience, which we applied to diabetic and nondiabetic patients in the operating room of our hospital. METHODS: The patients who underwent PSB for foot and ankle surgery between October 1, 2021, and December 31, 2021, in Sakarya University Training and Research Hospital were evaluated retrospectively. All nerve blocks were administered by a single anesthesiologist. Demographic data of the patients and the duration of the operation, the type of operation, the time of application of the nerve block, whether it was single or bifurcation block, and the onset times of motor and sensory block were also recorded in the perioperative period. RESULTS: It was determined that PSB was applied to 49 patients over a 3-month period. The mean age of the patients was 61.33 ± 14.03 years, and 12 patients (24.5%) were women. The reason why the patients were operated on was amputation in 21 (42.9%) and wound debridement in 27 (55.1%). There were 37 patients in the diabetic group and 12 patients in the nondiabetic group. There was no significant difference between the two groups in terms of demographic data and operation characteristics, but it was observed that there was a significant difference in both sensory and motor block formation times between the two groups (P < .001). CONCLUSIONS: In conclusion, we think that popliteal sciatic nerve block is easy to apply, the complication rate is low, and it is a suitable anesthesia method for patients who will undergo day surgery for foot ulcer.

Efficacy of Transpedal Retrograde Approach in Endovascular Treatment of Patients With Buerger's Disease.

BACKGROUND: Endovascular treatment of Buerger's disease is challenging, which usually impedes antegrade revascularization options. We aimed to evaluate the effectiveness of transpedal retrograde approach in patients with Buerger's disease with ambiguous proximal caps and/or previously failed endovascular intervention via antegrade approach. METHODS: Eighteen patients with the diagnosis of Buerger's disease who had previously failed antegrade endovascular interventions and/or ambiguous proximal caps were enrolled. Baseline demographic characteristics, severity of critical limb-threatening ischemia, wound scores, postprocedural pedal loop scores, and recovery or amputation rates were recorded. RESULTS: The patients presented with ischemic rest pain (n = 5, Rutherford stage 4), ischemic ulcers with minor tissue loss (n = 8, Rutherford stage 5), and severe ischemic ulcers or gangrene with major tissue loss (n = 5, Rutherford stage 6). Preprocedural wound score according to Saint Elian Wound Score System (SEWSS) was 15.72 ± 5.05. Retrograde transpedal puncture was achieved with an 89% success rate. Postintervention angiographic success rate was 100%. Postintervention Rutherford stage improved compared with preprocedural Rutherford stages (P<.01). In addition, the average SEWSS score decreased significantly after the interventions (P<.001). Postprocedural pedal loop score was found to be associated with SEWSS scores and amputation rates. CONCLUSIONS: Transpedal retrograde approach is a technically feasible and potentially effective treatment modality for Buerger's disease and may be considered as a first-line treatment option in the treatment of limb salvage, especially when proximal caps of target vessels are ambiguous or antegrade approach is unsuccessful.

Retrograde Guidewire-Assisted Remodeling Technique: A Novel Technique for Endovascular Recanalization of Occluded Arterial Origins in Critical Limb Ischemia.

PURPOSE: The main objective of this study is to describe the retrograde guidewire-assisted remodeling technique (REGART), a novel technique, and assess its feasibility, safety, and effectiveness in the recanalization of ostial arterial occlusions without a visible stump in the critical limb ischemia (CLI). MATERIALS AND METHODS: A retrospective review of 387 patients who underwent endovascular treatment (EVT) for peripheral artery disease between January 2020 and June 2021 was performed. Among these, 23 patients (14 males [60.8%]) with a mean age of 64.2 (range: 55-72) years who underwent REGART were included. Patient demographics, procedural details, and outcomes were noted. RESULTS: The technical success rate was 95.6% (22/23). The angiographic success rate was 86.3% (19/22). The procedure-related complication rate was 21.7% (5/23), with 4 (17.4%) major complications and 1 (4.3%) minor complication. CONCLUSION: In the CLI, results of this trial suggest that REGART is feasible, effective, and with acceptable safety in the catheterization of occluded artery origins without a visible stump when conventional anterograde and retrograde techniques fail. Thus, the target occluded artery can be recanalized while preserving other arterial origins by minimizing dissection risk through subintimal balloon angioplasty at the bi-trifurcation level.

Management of a complicated redo giant dissecting aortic aneurysm.

Giant aortic aneurysm is defined as an aneurysm of the aorta of greater than 10 cm in diameter. This rare condition is associated with a high risk of morbidity and mortality and it may lead to fatal complications such as rupture and/or dissection if not managed with proper surgical planning and expertise. Other than atherosclerosis, the main causes of giant ascending aortic aneurysms include Marfan and Ehlers-Danhlos syndromes. Herein we report on a young male patient who had had an aortic valve replacement five years earlier due to a bicuspid aortic valve leading to aortic failure, accompanied by aortic coarctation. He had an aneurysmal expansion rate of 1.81 cm/year to reach a final aneurysmal diameter of 13.25 cm, which, to our knowledge, represents the largest size ever reported in the literature for such lesions, and in which the redo and aneurysmal wall were adjacent to the sternal margins.

Outcomes of Mild to Moderate Functional Tricuspid Regurgitation in Patients Undergoing Mitral Valve Operations: A Meta-Analysis of 2,488 Patients.

This meta-analysis examined the prognosis of patients who were found to have mild to moderate functional tricuspid regurgitation during mitral valve operations. Overall, this meta-analysis included 2,488 patients in 10 studies. Compared with the group without tricuspid valve annuloplasty, the probability of not progressing to moderate to severe functional tricuspid regurgitation was significantly higher in the tricuspid valve annuloplasty group. A more aggressive surgical approach involving concomitant tricuspid repair with mitral valve operations may be considered to avoid the development of moderate to severe functional tricuspid regurgitation in the follow-up.

The Effects of Near-Infrared Spectroscopy on the Neurocognitive Functions in the Patients Undergoing Coronary Artery Bypass Grafting with Asymptomatic Carotid Artery Disease: A Randomized Prospective Study.

PURPOSE: The purpose of this study was to research the use of near-infrared spectroscopy (NIRS) on the neurocognitive functions in the patients undergoing coronary artery bypass grafting (CABG) with asymptomatic carotid artery disease. METHODS: The study design was carried out with the participation of 79 patients in a prospective, randomized and double blind control method. The patients were separated into two groups as NIRS (n = 43) and no NIRS (n = 36). A neurocognitive test was applied preoperatively and postoperatively to all patients before discharge. Cognitive functions were evaluated by applying the Montreal Cognitive Assessment test (MoCA). RESULTS: The decrease in the postoperative score of mean MoCA in no NIRS group was statistically significant when compared to preoperatively (p <0.001). Postoperative mean MoCA score was found to be significantly higher in NIRS group (NIRS: 26.8 ± 1.9 vs. no NIRS: 23.6 ± 2.5, p <0.001). It has been determined that there was a moderately positive significant correlation between the increase in the NIRS used patients (%) and increase in the MoCA score of the patients (r = 0.59, p <0.001). CONCLUSION: Intraoperative NIRS usage in the patients undergoing CABG with carotid artery disease might be useful due to its postoperative positive effects on the cognitive functions.

Posterior leaflet segment 2 plication in ischemic mitral regurgitation repair.

AIM: To evaluate the medium-term results of plication of posterior leaflet segment 2 in addition to ring annuloplasty in patients with functional ischemic mitral regurgitation. METHODS: The study included 136 patients who underwent mitral valve repair with plication of posterior leaflet segment 2 for ischemic mitral regurgitation between 2004 and 2012. The direction and correlation of left ventricle sphericity and tethering area were established by Pearson correlation analysis in patients with or without recurrent mitral regurgitation in the medium term. RESULTS: Medium-term survival was 91.9% and freedom from moderate or severe mitral regurgitation was 89.6%. In medium-term follow-up, transthoracic echocardiography found a significant decrease in tethering area, coaptation height, and distance between the commissures compared to the pre-surgery values (p = 0.0001 in all). The distance between the papillary muscles was reduced compared to the pre-surgery period but it was not significant (p = 0.204). Pearson correlation analysis found no significant correlation between the tethering area and left ventricle sphericity in patients without recurrent mitral regurgitation (r = 0.15, p = 0.36), a highly positive correlation (r = 0.44, p < 0.001) in patients with mild recurrent mitral regurgitation, and a moderately positive correlation (r = 0.71, p < 0.01) in patients with moderate or severe recurrent mitral regurgitation. CONCLUSIONS: The tethering area, coaptation height, and distance between the commissures decreased significantly, thus posterior leaflet segment 2 plication in addition to ring annuloplasty may be the optional procedure to ensure freedom from moderate or severe mitral regurgitation.

Postoperative revision surgery for bleeding in a tertiary heart center.

We analyzed cases of re-exploration for bleeding after 19,680 open heart operations performed between January 1995 and January 2009 to determine the risk factors for mortality and morbidity. Half of the 282 patients reexplored had nonsurgical causes of bleeding. The patients were grouped according to the timing of reoperation, early re-exploration being on the day of the operation. Mortality, total morbidity, and the need for transfusion of any blood product were compared between the early and late re-exploration groups. Most patients (77.7%) were reexplored early. Overall mortality was 8.5% (24 patients). Mortality, total morbidity, renal, gastrointestinal, neurologic and infectious complications, and low cardiac output differed significantly between the 2 groups. Significant predictors of mortality were old age, female sex, left ventricular dysfunction, noncoronary operations, and delayed reoperation. Predictors of morbidity were old age, preoperative dialysis, tobacco use, chronic lung disease, and delayed reoperation. No factors were found to be associated with the need for transfusion.

Hypercholesterolemia association with aortic stenosis of various etiologies.

BACKGROUND: Hypercholesterolemia has been found to be associated with aortic valve stenosis and to resemble the inflammatory process of atherosclerosis in many studies. The aim of this study was to investigate the role of hypercholesterolemia in development of aortic valve calcification in different etiologies. METHODS: The study included 988 patients with rheumatic, congenital, or degenerative aortic stenosis, who underwent aortic valve replacement at Kosuyolu Heart and Research Hospital between 1985 and 2005. Effects of hypercholesterolemia and high low-density lipoprotein level on calcific aortic stenosis or massive aortic valve calcification were analyzed for each etiologic group. RESULTS: Both univariate and multivariate analyses revealed that the high serum cholesterol level (>200 mg/dL) was related to massive aortic valve calcification in all patients (p = 0.003). Hypercholesterolemia was linked to calcific aortic stenosis and massive calcification in patients with degenerative etiology (p = 0.02 and p = 0.01, respectively) and it was related to massive calcification in patients with congenital bicuspid aorta (p = 0.02). Other independent risk factors for calcific aortic stenosis and massive calcification in the degenerative group were high low-density lipoprotein level (>130 mg/dL; p = 0.03 and p = 0.05, respectively) and high serum C-reactive protein level (p = 0.04 and p = 0.05, respectively). CONCLUSIONS: Hypercholesterolemia is related to increased risk of aortic valve calcification in patients with degenerative and congenital etiology. Preventive treatment of hypercholesterolemia could play an important role to decrease or inhibit development of aortic valve calcification.