Can the arterial clamp method be used safely where a tourniquet cannot be used?

BACKGROUND: Clamp application is safe and widely used in the visceral organs. This raises the question: why not use clamping in orthopaedic, oncological, fracture and revision surgeries of areas where tourniquets are not suitable. This experimental animal study aimed to compare tourniquet and arterial clamp applications with regard to their histological effects and inflammatory responses on a molecular level, on the artery, vein, nerve and muscle tissue. METHODS: Twenty-one rabbits were divided into three groups (group I: proximal femoral artery clamp; group II: proximal thigh tourniquet; and group III: control group). In the clamp group, the common femoral artery was clamped with a microvascular clamp for two hours. In the tourniquet group, a 12-inch cuff was applied to the proximal thigh for two hours at 200 mmHg. The common femoral artery, vein, nerve, rectus femoris and tibialis anterior muscles were excised and analysed in all groups. RESULTS: Artery and vein endothelial injuries were found in the clamp and tourniquet groups (relative to the control group, p ≤ 0.001 and p = 0.007, respectively). However, no difference was found between the clamp and tourniquet groups regarding vessel wall injury. CONCLUSIONS: We found there were no differences in incidence of vessel, muscle and nerve injury when comparing the tourniquet and clamp applications. For surgical procedures that are unsuited to a tourniquet, arterial clamping can be selected, resulting in close-to-tourniquet vessel injury rates but without tourniquet-related complications.

Comparative efficacy and life quality effects of surgical stripping, radiofrequency ablation, and cyanoacrylate embolization in patients undergoing treatment for great saphenous vein insufficiency.

OBJECTIVES: To compare traditional surgery with two minimally invasive endo-venous procedures in terms of their long-term effect on the quality of life in great saphenous vein insufficiency (GSV). METHOD: This prospective observational study included 217 patients that underwent surgical stripping (n = 62), radiofrequency ablation (n = 70), or cyanoacrylate embolization (n = 85) for the treatment of GSV insufficiency. Venous Clinical Severity Score (VCSS) assessments were made, 36-item Short-Form Health Survey (SF-36) questionnaire and Chronic Venous Insufficiency quality of life Questionnaire (CIVIQ-14) were administered, before and 1 year after the treatments. RESULTS: Surgical stripping group had significantly higher closure rates than the other groups (p < 0.05). At 12 months, decrease in VCSS scores was less pronounced in the cyanoacrylate embolization group when compared to the other two groups (p < 0.05). Improvement in CIVIQ-14 scores was better in the radiofrequency ablation group when compared to the cyanoacrylate embolization group (p < 0.05). Surgical stripping or radiofrequency ablation groups performed better on several domains of SF-36, when compared to the cyanoacrylate embolization group. CONCLUSIONS: Surgical stripping and radiofrequency ablation seem to provide a better quality of life results at one year in patients undergoing treatment for GSV insufficiency.

Multiple Non-Essential Transition Metals Are Accumulated in Carotid Atherosclerotic Plaques: Missing Link in Atherosclerosis?

Population studies revealed that metal exposure through food, environment, and smoking was related with increased risk of cardiovascular disease. In this study, we determined complex chemical elements in surgical carotid endarterectomy specimens and carotid tissues from autopsies without atherosclerosis. Atherosclerotic plaques from 41 endarterectomies and normal carotid tissue from 30 autopsies were collected and elemental composition was determined by inductively coupled plasma optical emission spectrometry (ICP-OES) method. Eleven (26.8%) patients never smoked in carotid endarterectomy group. One patient was brass souvenir worker and one was goldsmith and others did not have direct contact with metals in the carotid endarterectomy group. Na, Cu, Mn, Bi, Co, Mo, Ni, Pb, Sb, Se, Sn, Ti, and W levels were not different between two groups. Bi, Co, Mo, Pb, Ti, and W were below the detection limit of ICP-OES in both groups. Concentrations of Mg, K, Ca, P, Fe, B, Zn, Al, As, Cr, Pt, and Hg were significantly higher in carotid endarterectomies than normal carotid tissue samples. Cd and S values were significantly higher in autopsy samples. There is significant multiple non-essential transition metal accumulation in atherosclerotic carotid endarterectomy plaques. The cardiovascular consequences of metal toxicity have not been researched adequately due to large emphasis on the role of cholesterol in atherosclerosis. High level of non-essential transition metal elements in the carotid atherosclerotic plaques may add the missing link of atherogenesis and may necessitate new treatment and prevention strategies in carotid disease if confirmed by further research.

Effects of Cilostazol and Diltiazem Hydrochloride on Ischemia-Reperfusion Injury in a Rat Hindlimb Model.

OBJECTIVE: Free radicals and neutrophils are potent sources of ischemia-reperfusion injury (I/R) and they can be limited by the use of exogenous application of some therapeutic agents. The objective of this study was to compare the effects of cilostazol and diltiazem hydrochloride in a rat hind limb model of I/R injury. Methods: Skeletal muscles submitted to 2 hours of ischemia by placing an aneurysm clip to femoral artery and reperfused after 1, 2 and 4 hours. Seventy-two Wistar-Albino rats were randomly divided into mainly four groups according to treatment agents:  Group I (control group) was treated with saline; Group II was treated with diltiazem hydrochloride; Group III was treated with cilostazol in 30% dimethyl sulphoxide; and Group IV was treated with 30% dimethyl sulphoxide intraperitoneally. These four main groups also subdivided into three subgroups according to duration of the reperfusion times.  Blood samples were taken and all rats were sacrificed. Results: Cilostazol-treated groups demonstrated a significant decrease in tissue and serum malondialdehyde (MDA) levels, and tissue myeloperoxidase (MPO ) activity compared with other groups. Increase in serum nitric oxide (NOx) level was significantly higher in all subgroups of cilastazol, diltiazem hydrochloride, and dimethyl sulphoxide groups versus the control group. CONCLUSION: Although these results suggest the beneficial effects of cilostazol and diltiazem hydrochloride on I/R injury, the effect of cilostazol on I/R injury seems to be more efficient than diltiazem hydrochloride.

The relationship between left ventricular mass index and body composition in new-diagnosed hypertensive patients.

BACKGROUND: Cardiovascular disease (CVD) is considered a public health burden and most common cause of mortality in all over the world. The latency time for developing CVD may be several decades. the objective of this study was to examine the relationship between body composition and Left Ventriculare Mass Index (LVMI) in newly diognosed hypertensive patients. METHODS: We enrolled 120 new-diagnosed hypertensive patients (mean age 45 ± 8 years) who admitted to our nephrology clinic. Body fat percentage (BFP) was measured by bioelectrical impedance (BIA). Echocardiography examinations were performed for all patients. RESULTS: Mean values of Waist hip ratio, Body mass index, Body fat percentage, Systolic blood pressure, Diastolic blood pressure were significantly higher for females than males (all p values <0.05). The female patients had higher LVMI than male patients (94.8 ± 13.1 vs 89.2 ± 14.6, p < 0.05). The study patients were divided into 3 groups according to their BFP defined by BIA. Group 3 patients, who exhibited higher body fat, had significantly higher BMI (p < 0,05), total leukocyte count (p < 0.05), CRP (p < 0.05), triglyceride (p < 0.05), and female predominance. Group 3 patients were statistically older than group 1 patients (46.2 vs. 40.6 years, p < 0.05). Additionally, LVMI levels were higher in Group 3 than Group 1 (p < 0.05) (Table 3). In logistic regression analysis, independent factors affecting LVMI were age, weight, gender and BFP (all p values were <0.05). CONCLUSIONS: BFP was associated with higher LVMI, in newly diognosed hypertensive patients. Its use results in significantly lower proportions of individuals with LVH in the population, in particular among hypertensive and the obese patients.

Straight versus S-shaped sternotomy: a histologic study in the sheep model.

INTRODUCTION: Straight sternotomy is the most common access for open heart surgery. Techniques have been proposed for maximizing sternal stability in high-risk patients. This trend implies a growing need for newer surgical techniques. The aim of this experimental study in the sheep model is to evaluate median vs. S shaped sternotomy the feasibility of using a special device to accelerate the sternal instability and bone healing. MATERIALS AND METHODS: We enrolled 31 sheep, weighing 18-30 kg. For all animals a midline skin incision was made. In group I (n = 16 animals), straight median sternotomy and in group II (n = 15 animals), S-shaped incision was marked on the periosteum of the sternum by new created device for standard S-shaped sternotomy. Sternum biopsies were performed on second surgery month for all survived animals from the sternum and the surrounding soft tissue. RESULTS: No early superficial wound complications were observed. Overall mortality in the initial approach group was 19.3% (6 sheep). In group I; 3 sheep had died on first surgery day, the reason may be hemorrhage and in group II; 3 sheep developed intractable VF during surgery procedure or immediately afterwards so died. There were statistically significant differences in the scores of bone healing between group 1 and group 2 (4.2 vs.7.3, ANOVA, p < 0.001). DISCUSSION: Our work is based on the use of a standard S-shaped sternotomy procedure on sheep sternum. In our experience with the sternal healing in the sheep model, the process of new bone formation was accelerated with S- shaped cut than straight sternotomy procedure.

Single coronary artery anomaly causing ischemic mitral insufficiency.

Single coronary artery anomaly is rarely seen, and although it can present with sudden death, chest pain, arrhythmia, myocardial infarction, or congestive heart failure, it can also be asymptomatic. We describe the case of a 58-year-old man with single coronary artery anomaly in whom the coronary artery stemmed from the left coronary sinus and caused ischemic mitral insufficiency due to left anterior descending artery stenosis. He underwent successful mitral valve repair and coronary bypass.

A giant right atrial villous myxoma with simultaneous pulmonary embolism.

INTRODUCTION: Primary cardiac tumors are rare and approximately three quarters of them are benign and up to half of the benign tumors are myxomas. Right atrial villous myxoma with pulmonary embolism is an unusual apparition. PRESENTATION OF CASE: A 29 year-old male was admitted to our outpatient clinic with progressive exertional dyspnea, chest pain and intermittent feeling faint. A giant right atrial villous mobile mass was detected by means of transthoracic echocardiography. To exclude possible pulmonary embolism, chest computed tomography scan was performed and showed filling defects in the branch of the pulmonary artery. The mass was totally resected. DISCUSSION: RA villous myxoma is a rare subtype in an unusual location with high potential of pulmonary embolism. Early surgery for villous myxoma has a great importance in order to reduce the risk of pulmonary embolism. CONCLUSION: 3D TEE should be a sufficient technique for diagnosis and evoluation of shape, size and origin of the cardiac mass an adequate guide to surgical treatment.

Ischaemic mitral regurgitation: The effects of ring annuloplasty and suture annuloplasty repair techniques on left ventricular re-remodeling.

OBJECTIVE: To examine the mid-term results of patients on whom a coronary revascularization as well as a mitral ring and suture annuloplasty have been performed due to coronary artery disease (CAD) and ischaemic mitral regurgitation (IMR). METHODOLOGY: Totally 73 patients on whom a revascularization and a mitral valve repair due to CAD and IMR had been performed in our clinic between 2000-2008 were included in the study. Patients were divided into two groups one of which included 38 patients (52.05%) on whom a coronary artery bypass graft (CABG) and a ring annuloplasty on the mitral valve had been performed (Group 1) and the other one 35 patients (47.95%) on whom only suture annuloplasty as well as a CABG had been performed (Group 2). The study was planned retrospectively and study data have been obtained by screening the hospital registries retrospectively. In the mid-term, patients were invited for a check and their intragroup and intergroup echocardiographic parameters and functional capacities were assessed statistically. RESULTS: In pre-operational and post-operational intragroup assessment in terms of echocardiographic findings; although LVEDD, LVESD, EDV, PAP and the degree of recurrent MR have been decreased in both groups, the decrease in LVESD and PAP and the low degree of recurrent MR were statistically significant in Group 1 patients (p=0.047, p=0.023, p=0.01, respectively). When the mid-term intergroup echocardiograpic findings were assessed; PAP and recurrent MR have been determined statistically lower in Group 1 patients (p=0.005, p=0.08, respectively). The length of intensive care unit stay, length of hospitalization and length of detachment from respiratory support were statistically significantly longer in ring annuloplasty performed group (p=0.012, p=0.033, p=0.029, respectively). CONCLUSIONS: In moderate to severe IMR patients, a positive contribution can be provided to ventricular remodeling by a ring annuloplasty through a significant decrease in left ventricular diameter and a low recurrent MR and PAP.

Effects of ischemic preconditioning and iloprost on myocardial ischemia-reperfusion damage in rats.

This study investigates the effects of cardiac ischemic preconditioning and iloprost on reperfusion damage in rats with myocardial ischemia/reperfusion. 38 male Wistar Albino rats used in this study were divided into 5 groups. The control group (Group 1) (n=6), ischemia/reperfusion (IR) group (Group 2) (n=8), cardiac ischemic preconditioning (CIP) group (Group 3) (n=8), iloprost (ILO) group (Group 4) (n=8), and cardiac ischemic preconditioning + iloprost (CIP+ILO) group (Group 5) (n=8). Pre-ischemia, 15 minutes post-ischemia, 45 minutes post-reperfusion, mean blood pressure (MBP), and heart rates (HR) were recorded. The rate-pressure product (RPP) was calculated. Post-reperfusion plasma creatine kinase-MB (CK-MB), lactate dehydrogenase (LDH), troponin (cTn) vlaues, and infarct size/area at risk (IS/AAR) were calculated from myocardial tissue samples. Arrhythmia and ST segment elevations were evaluated during the ischemia and reperfusion stages. Although the MBP, HR, RPP values, biochemical parameters of CK-MB and LDH levels, IS/AAR rates, ST segment elevation values were found to be similar in CIP and CIP+ILO groups and the IR and ILO groups (p>0.05), CIP-containing group values had a positively meaningful difference (p<0.05) compared with the IR and ILO group. While mild-moderate findings of damage were observed in Group 3 and Group 5, severely findings of damage were releaved in Group 2 and Group 4. The arrhythmia score of the ILO group was meaningfully lower (F: 41.4, p<0.001) than the IR group. We can conclude that the effects of myocardial reperfusion damage can be reduced by cardiac ischemic preconditioning, intravenous iloprost reduced the incidence of ventricular arrhythmia associated with reperfusion, and its use with CIP caused no additional changes.

The effects of levosimendan exposure on oxidant/antioxidant status and trace element levels in the pulmonary artery of rats.

We investigated both the effect of levosimendan and the role of oxidant/antioxidant status and trace element levels in the pulmonary artery of rats. Fourteen male Wistar albino rats were randomly divided into two groups of seven animals each. Group 1 was not exposed to levosimendan and served as a control. Levosimendan (12 µg/kg) diluted in 10 ml 0.9 % NaCl was administered intraperitoneally to group 2. Animals of both groups were killed after 3 days, and their pulmonary arteries were harvested to determine changes in tissue oxidant/antioxidant status and trace element levels. The animals in both groups were killed 72 h after the levosimendan exposure treatment, and pulmonary arteries were harvested to determine levels of the lipid peroxidation product MDA and the antioxidant GSH as well as the decreased activity of antioxidant enzymes such as SOD, GSH-Px and CAT. It was found that MDA levels increased in pulmonary artery tissues of rats after levosimendan administration. The GSH level decreased in the pulmonary artery of rats after levosimendan treatment. Co, Mn, Fe, Cd and Pb levels were significantly higher (P < 0.001) and Mg, Zn and Cu levels significantly lower (P < 0.001) in the levosimendan group compared to the control group. These results suggest that levosimendan treatment caused an increase in free radical production and a decrease in antioxidant enzyme activity in the pulmonary artery of levosimendan-treated rats. It also caused a decrease or increase in the levels of many minerals in the pulmonary artery, which is an undesirable condition for normal pharmacological function.

Comparison of the health related quality of life of patients following mitral valve surgical procedures in the 6-months follow-up: a prospective study.

PURPOSE: The aim of the present study is to evaluate the health-related quality of life of the patients who underwent mitral valve repair (MvRp) and mitral valve replacement (MVR). METHODS: Within the scope of this prospective study design, 56 patients who had mitral valve operation between the years of 2011-2012 were enrolled in the study. 24 (42.8%) of these patients had MVR while 32 (57.1%) of them had MvRp. The health-related quality of life was evaluated according to the Turkey norms of Short Form 36 Quality-Of-Life Measures (SF-36), which were filled in by the patients before and 6 months after the operation. Moreover, preoperative risk factors affecting the quality of life (age, gender, functional capacity, rhythm, hypertension, diabetes, applied surgical method and echocardiographic results) were investigated for all the patients (n = 56) by using independent sample t test analysis. RESULTS: When the pre and postoperative changes were compared between the two groups, it was found out that there were no significant difference between the groups in terms of restraints on physical role functioning (PR), and the social role functioning values (SF) (respectively; p = 0.097, p = 0.105). However, in the comparison of pre-/postoperative changes between the groups, the changes in physical functioning (PF), bodily pain (BP), general health (GH), vitality (VT) and restraints on emotional role functioning (RE) and mental health (MH) values were found out to be significantly superior in the MvRp group than in the MVR group (respectively; p <0.01, p <0.05, p <0.01, p <0.01, p <0.05 and p <0.01). It was also confirmed that female gender, atrial fibrillation (AFR), and MVR method negatively affected the physical and mental components (respectively; p = 0.033, p = 0.003, p = 0.015). CONCLUSION: RESULTS of the SF-36 quality of life measures show that quality of life may be better in patients that have had MvRp. It should be considered that the planned surgical treatment method can affect the patient's quality of life, and this effect can indicate the success of the surgical treatment.

Surgical treatment of lower limb ischemia in diabetic patients - long-term results.

INTRODUCTION: Lower limb ischemia may cause nonhealing ulcers, infection, amputation and even mortality in diabetic patients. In this study, we review our data of ischemic lower limb revascularization procedures in diabetic patients and present the early, mid- and long-term results. MATERIAL AND METHODS: From March 2004 to September 2008, 83 patients with lower limb ischemia in Fontaine class III and IV underwent distal arterial bypass procedures. Saphenous vein grafts were used for below-knee arterial bypasses in all patients. In 16 (19%) patients femoropopliteal bypasses were performed with PTFE grafts. Short-term and long-term surgical results were evaluated. RESULTS: Ulcer recovery was determined in 36% of patients. Graft patency was 95% and 1 death (1%) occurred in short-term follow-up. In long-term follow-up the total effectiveness rate was 74%. Graft patency was 79% and 6 deaths (7%) occurred during the follow-up. CONCLUSIONS: Lower limb ischemia is a serious event in patients with diabetes mellitus. The consequences may include increased mortality and morbidity in this particular patient population. However, distal arterial revascularizations are considerably effective procedures to avoid amputation, to eliminate symptoms, to promote ulcer recovery and to help the patient participate in social life with acceptable short, mid- and long-term follow-up results.

Analysis of the influences of short-term levosimendan exposure on oxidant/antioxidant status and trace-element levels in the physiological status of the thoracic aorta of rats.

The objective of this study was to evaluate the effect of levosimendan (chemical formula C14H12N6O) exposure on oxidant/antioxidant status and trace-element levels in the thoracic aorta of rats. Eighteen male Wistar albino rats were randomly divided into two groups of eight animals each. Group 1 was not exposed to levosimendan and served as a control. Levosimendan (12 µg/kg) diluted in 10 ml 0.5 % dextrose was administered intraperitoneally to group 2. Animals of both groups were killed after 3 days, and their thoracic aortae were harvested for determination of changes in tissue oxidant/antioxidant status and trace-element levels. The animals in both groups were killed 72 h after levosimendan exposure, and thoracic aortae were harvested for determination of the lipid peroxidation product MDA and antioxidant GSH levels and the activities of antioxidant enzymes such as SOD, GSH-Px and CAT. It was found that MDA, GSH and CAT enzyme levels increased in thoracic aortae of rats after levosimendan administration. SOD and CA enzyme activities and the level of antioxidant GSH decreased in thoracic aortae of rats after levosimendan treatment. Pb, Cd and Fe levels of thoracic aortae were significantly higher (P < 0.001) and Mg, Mn, Zn and Cu were significantly lower (P < 0.001) in the levosimendan group compared to the control group. These results suggest that short-term levosimendan treatment caused an increase in free radical production and a decrease in antioxidant enzyme activity in thoracic aortae of levosimendan-treated rats. It also causes a decrease or increase in many mineral levels of the thoracic aorta, which is an undesirable condition for normal pharmacological function.

Regional block anesthesia in a patient with factor V Leiden mutation and axillary artery occlusion.

Anesthetic management of patients with coagulation disorders presents safety and technical challenges. This case describes a 58-year-old woman with factor V Leiden mutation who required distal saphenous vein harvest and axillo-brachial bypass to treat axillary artery occlusion. The patient underwent surgery with satisfactory anesthesia using infraclavicular brachial plexus block, thoracic paravertebral block, and unilateral subarachnoid block. These three regional anesthetic interventions were performed in lieu of general anesthesia to minimize risks of thrombotic events, pain, and to decrease recovery time. Despite higher failure rates of regional anesthesia, longer time required for procedures, and added discomforts during surgery, the benefits may outweigh risks for selected high-risk patients, including those with factor V Leiden mutations.

Splenomegaly in primary antiphospholipid syndrome without accompanying portal hypertension or comorbidity.

OBJECTIVE: To demonstrate the presence of splenomegaly in primary antiphospholipid syndrome (PAPS) patients without accompanying portal hypertension or comorbidity. METHODS: Twelve patients (7 women) aged 23-65 years followed upon the diagnosis of PAPS were enrolled in the study. We documented the identified causes of splenomegaly in patients with PAPS, and searched for the potential causes of splenomegaly in patients with spleen enlargement. PAPS patients with or without splenomegaly were evaluated in terms of demographic and clinical findings. RESULTS: Splenomegaly was present in 6 of the 12 patients. In these patients, there were no infections, hematological disorders, portal hypertension or malignancy that might lead to splenomegaly. The long axis of spleen was found to be in the range of 137-155 mm in patients with splenomegaly. Splenomegaly was more frequently determined in female PAPS patients. The splenomegaly group had a longer duration of disease (median 5.5 vs. 0.75 years) and a higher number of thrombotic events (median 3 vs. 1.5). The splenomegaly group was especially composed of patients who never received any anticoagulant and acetylsalicylic acid, or who used these agents irregularly for very short periods. CONCLUSION: Splenomegaly was observed in association with disease duration, frequency of thrombotic events and irregular antiaggregant or anticoagulant treatment in patients with PAPS, in the absence of comorbidity or portal hypertension.

Effects of atorvastatin on vascular intimal hyperplasia: an experimental rodent model.

INTRODUCTION: Vascular intimal hyperplasia is associated with increased mortality and morbidity. The authors investigated the effects of atorvastatin on vascular intimal hyperplasia. MATERIALS AND METHODS: Rats were divided into 4 groups. Groups 1, 2, and 3 had experimental aortic injury and received intraperitoneal injection of atorvastatin, solvent, or 0.9% NaCl, respectively. Group 4 was a nonintervention (laparotomy only) control group. Animals were sacrificed after 3 weeks. Blood samples and injured aortic segment were analyzed. RESULTS: Atorvastatin administration significantly lowered total and low-density lipoprotein cholesterol levels (P = .012 and P = .001, respectively), intima-media ratio (P = .002), and intimal smooth muscle cell accumulation (P < .05) in group 1. Luminal narrowing in animals in group 1 was significantly lower than that in animals in groups 2 and 3, but was higher than in animals in group 4 (P = .009). CONCLUSIONS: Atorvastatin suppresses intimal hyerplasia and aids in intimal regeneration by lowering blood lipids and intimal smooth muscle cell accumulation.