Mid-term results of tunneled brachial venous hemodialysis catheter placement: Our single-center experience with 21 patients.

BACKGROUND: This study aims to analyze the safety and efficacy of permanent hemodialysis catheter insertion via the brachial vein in unsuitable patients for catheter insertion from other vascular access sites. METHODS: A total of 21 patients (6 males, 18 females; mean age: 54.4±11.3 years; range, 48 to 77 years) who underwent permanent hemodialysis catheter insertion via the brachial vein between February 2019 and February 2020 were retrospectively analyzed. All patients underwent brachial venous tunneled catheter insertion under the ultrasound guidance and under local anesthesia. Transthoracic echocardiography was performed before and six months after catheter insertion. The primary patency rate of the catheter at six months of follow-up, potential associated complications of a permanent hemodialysis catheter including catheter thrombosis and catheter infections, and all-cause mortality rates were recorded. RESULTS: Catheter removal was required in eight patients (catheter thrombosis, n=5; catheter infection, n=2; and extensive hematoma, n=1). The catheters were patent in the remaining 13 (62%) patients at six months. Mortality occurred in one patient due to bacterial pneumonia. No life-threatening complications including hemothorax or pneumothorax and neurological injury was observed in any of the patients. CONCLUSION: Our study results show that brachial venous tunneled catheter placement for hemodialysis can be a safe and valid alternative to catheter insertion from the jugular or subclavian veins for vascular access in patients with end-stage renal disease.

Should We Postpone Elective Cardiovascular Procedures and Percutaneous Coronary Interventions During the COVID-19 Pandemic?

BACKGROUND: Prioritization among patients with coronary artery disease represents a difficult issue during the SARS-CoV-2 pandemic. We present our clinical practices and patients' outcomes after elective, emergent, and urgent cardiovascular surgery and percutaneous coronary interventions (PCI). We also investigated the rate of nosocomial infection of SARS-CoV-2 in health workers (HWs), including surgeons after cardiovascular procedures and percutaneous interventions (PCI). MATERIAL AND METHODS: We performed 186 cardiovascular operations and PCI between March 15 and October 15. According to the level of priority (LoP), we performed urgent and emergent coronary artery bypass grafting (CABG) and cardiac valve repair or replacement surgery in 44 patients. In one patient with acute chordae rupture with pulmonary edema, we performed mitral valve replacement. We performed the aortic arch repair in two patients with type-I aortic dissection in urgent situations. Therefore, in 47 patients we performed cardiac operations in urgent or emergent situations. Elective CABG (N = 28) and elective cardiac valve (N = 10) surgeries were performed (total: 38). While rescue PCI was urgently performed in 47 patients with ST-segment elevation myocardial infarction (STEMI), it was performed in elective or emergent situations in 40 patients with myocardial ischemia. Endovascular treatment was performed in four patients with deep venous thrombosis (DVT) and in four patients with chronic arterial occlusion, respectively. Surgical vascular repair and embolectomy were performed in patients with peripheral artery injury (N = 6) and acute arterial embolic events (N = 4), respectively. We performed thoracic computed tomography followed by reverse transcriptase-polymerase chain reaction (RT-PCR) test in patients with irregular diffuse reticular opacities with or without consolidation on chest X-ray. Blood coagulation disorders including d-dimer, thromboplastin time (TT), and partial thromboplastin time (aPTT) were measured prior to procedures. RESULTS: No mortality and morbidity was seen after percutaneous and surgical arterial or venous procedures. The total mortality rate was 4.1% (8 of 186 CAD patients or valve surgery) after urgent and emergent CABG (N = 4), an urgent valve replacement (N = 1), and PCI (N = 3). Low cardiac output syndrome (LOS) and major adverse cardiac cerebrovascular event (MACCE) were the mortality factors after cardiac surgery. The reasons for death after PCI were sudden cardiac arrest related to the dissection of the left main coronary artery during procedure and pneumonia due to COVID-19 (N = 2). Ground-glass opacities in combination with pulmonary consolidations were detected in seven patients. Interlobular septal and pleural thickening with patchy bronchiectasis in the bilateral lower lobe involvement was found after thoracic computed tomography in these patients. We confirmed in-hospital COVID-19 using a PCR test in two patients with STEMI prior to PCI. PT and aPTT increased, but fibrin degradation products did not in those two patients. We confirmed COVID-19 via phone call in six CABG patients and one PCI patient after discharge from the hospital. None of the patients diagnosed with COVID-19 died after being discharged from the hospital. CONCLUSION: Cardiovascular surgery and PCI can safely be performed with acceptable complications and mortality rates in elective situations, during the COVID-19 pandemic. Preoperative control of OR traffic, careful evaluation of the patient's history, consultation, and precautions taken by healthcare professionals are important, during and after procedures. Also important is wearing a mask and face shield and careful disinfection of equipment and space.

Health-related quality of life after vascular surgery and endovascular treatment in subjects with critical limb ischemia.

BACKGROUND & OBJECTIVE: Revascularization of the target vessel and restoration of distal flow is critical not only to reduce mortality and morbidity but also improve health-related quality of life (HRQoL) in patients with critical limb ischemia. However, data concerning the impact of surgical bypass and percutaneous transluminal angioplasty (PTA) on HRQoL is limited. This study aimed to compare the impact of surgical bypass and PTA on HRQoL in subjects undergoing superficial femoral artery (SFA) or popliteal artery revascularization. METHODS: Seventy-one subjects who underwent successful revascularization of the SFA or popliteal artery either with surgical revascularization or PTA were enrolled in this study. Three months after revascularization, all subjects underwent ankle-brachial index (ABI) measurement, 6-minute walking test and completed the Nottingham Health Profile (NHP) questionnaire. The NHP score differences (measured at the post-procedural 3rd month) between subjects undergoing surgical or endovascular (PTA) revascularization subjects was the primary outcome measure of the study. RESULTS: Both groups experienced significant improvements in ABI and 6-minute walking distance at post-procedure three months. NHP total scores of Part I and Part II at post-procedural six months were similar in the two groups. However, social isolation [77.98 (0 - 85) vs. 22.53 (0 - 100), p=0.002] and physical abilities [78.7 (30.31 - 87.7) vs. 54.47 (0 - 100), P=0.014] domain scores of the surgical revascularization group were significantly higher than that of the endovascular treatment group. CONCLUSION: This study shows that total scores obtained from the NHP questionnaire applied three months after revascularization of SFA stenosis are similar in subjects undergoing surgical revascularization or PTA. However, the social isolation and physical abilities domains of the NHP are significantly higher in subjects receiving surgical revascularization compared to those receiving PTA.

The safety and efficacy of pharmaco-mechanical thrombolysis in lower-extremity deep venous thrombosis.

OBJECTIVE: The aim of this study was to investigate the impact of accelerated pharmaco-mechanical thrombolysis (PMT) with low-dose second-generation urokinase for the management of cases with lower-extremity deep venous thrombosis (DVT), and to compare its efficacy in subjects with acute and subacute DVT. METHODS: Thirty-five patients with acute (< 15 days) or subacute (15-30 days) DVT who underwent PMT in a tertiary centre were enrolled in this single-arm, prospective study. Following the placement of a temporary vena cava filter, urokinase (200 000 IU) was administered into the occlusion through a multi-hole catheter for 15 to 20 minutes. Control venography was performed to assess venous flow and the rate of acute recanalisation. Percutaneous balloon dilatation and stent placement were carried out in case of a residual iliac vein stenosis of > 50%. Any residual thrombi were suctioned with an aspiration catheter. The primary outcome measures of this study were the percentages of vessel patency and PTS in the third month after PMT. RESULTS: Complete recanalisation was noted in 23 (66%) patients, while two (6%) had poor recanalisation. The rate of minor complications was 14%. None of the subjects experienced major complications, such as intracranial haemorrhage or pulmonary embolism. No mortality was recorded during the three months of follow up. Control duplex ultrasonography in the third month revealed that the target vein was patent in all subjects. None of the subjects experienced PTS during follow up. In addition, the percentage of acute complete recanalisation was significantly higher in subjects with acute DVT compared to those with subacute DVT (95 vs 27%, p < 0.001). CONCLUSION: PMT with an accelerated regimen of low-dose urokinase provided excellent efficacy in the resolution of thrombus and prevented the development of PTS in the midterm when used for the management of lower-extremity DVT.

Retrograde Versus Antegrade Approach for the Endovascular Treatment of Symptomatic Femoropopliteal Disease: Results of the 2-Year Follow Up.

OBJECTIVE: To compare the antegrade and retrograde approaches, in terms of access site complications and long-term patency in subjects undergoing EVT for symptomatic SFA or popliteal artery stenosis or occlusions. METHODS: All consecutive patients who underwent retrograde recanalization for partial stenosis or chronic total occlusion of the SFA or PA at 2 centers were enrolled in this retrospective analysis. Subjects were divided into 2 groups, according to the approach selected for EVT as antegrade approach group or retrograde approach group. The rate of primary patency, which was defined as the lack of restenosis at the target lesion, was the primary outcome measure, during the follow-up evaluations. The rate of procedural complications, including hematoma, bleeding, and distal embolism, were secondary outcome measures. RESULTS: A significant improvement occurred in ABI, following the intervention in both the antegrade approach group [0.7 (0.3 - 1.1) versus 0.85 (0.4 - 1.3), P < 0.001] and retrograde approach group [0.5 (0.3 - 1.1) versus 0.8 (0.3 - 1.3), P < .001]. The primary patency rate at the 1st, 6th, 12th and 24th months of the intervention in the antegrade approach group were 94.85%, 83.82%, 74.26%, and 66.91%, respectively. The primary patency rate at the 1st, 6th, 12th, and 24th months of the intervention in the retrograde approach group were 93.33%, 86.67%, 84.44%, and 71.11%, respectively. The groups were similar with respect to the primary patency rates. The rate of complications, including hematoma, bleeding, and distal embolization was similar in the 2 groups. CONCLUSION: Antegrade approach and retrograde approach provide a similar safety profile in the EVT of SFA and popliteal artery stenosis and occlusion. The primary patency rates at the 1st, 6th, 12th, and 24th months of follow up also were similar in the 2 groups. However, the significant difference in the lesion characteristics of the subjects undergoing retrograde or antegrade approach complicates the ability to reach a clear conclusion, regarding the superiority of one technique over the other.

Two-Year Follow-Up After Endovascular Therapy of Superficial Femoral Arteries with Retrograde Popliteal Approach: Single-Center Experience.

OBJECTIVE: Popliteal artery puncture, which makes possible the use of lower profile sheaths and devices, has gained popularity as an alternative to the antegrade approach, due to the reduction in vascular complications at the access site. The present study aimed to analyze the safety of the procedure and long-term patency of the superficial femoral artery (SFA) and popliteal artery (PA) and in subjects undergoing recanalization with the popliteal retrograde approach. METHODS: Forty-three subjects, who underwent endovascular therapy (EVT) of the SFA or PA with retrograde popliteal approach, were enrolled in this retrospective study. The decision for the retrograde approach was made according to pre-intervention CT angiography results (severe calcification and relatively long CTO segment) in 20 of the subjects. The remaining 23 subjects underwent SFA or PA recanalization with the retrograde approach, due to failed antegrade recanalization attempt. All patients underwent color duplex ultrasound at the first, sixth, 12th, and 24th months to determine patency. The rate of procedural complications, including hematoma, bleeding, and distal embolism, were recorded for all subjects. RESULTS: Technical success was achieved in all cases. Access site complications, including hematoma and bleeding, were observed in 2 subjects (4.66%). Transfusion or surgical treatments were not required in any cases with access site complications. The acute success rate was defined as the recovery of good blood flow evaluated by angiography after EVT was 100%. Distal embolization, which did not cause any limitations in distal flow, occurred in 1 subject (2.33%). Ankle-brachial index (ABI) calculated at 1 month post-intervention was significantly higher than pre-intervention ABI [0.9 (0.59 - 1.3) versus 0.7 (0.4 - 1.1), P < .001]. Patency rates, as determined by ultrasonographic assessment at post-interventional first, sixth, 12th, and 24th months, were 100%, 95.34%, 88.37%, and 86.04%, respectively. CONCLUSION: Our findings demonstrate that retrograde popliteal artery puncture can be used as a safe and effective technique for recanalization of SFA and PA stenosis and occlusions. The retrograde popliteal approach provides excellent long-term primary patency rates.

Ultrastructural Investigations of Arterial Bypass Conduits after the Use of Different Harvesting Techniques Using an Electron Microscope.

OBJECTIVES: The aim of this study was to perform morphometric analysis of arterial conduits harvested by harmonic scalpel in coronary artery bypass grafting (CABG) patients. METHODS: From 100 CABG patients, 200 arterial conduits-100 radial arteries (RAs) and 100 left internal thoracic artery (LITAs)-were harvested. The patients had similar characteristics (mean age, sex ratio, comorbidities, etc.). We divided the patients into 2 groups according to harvesting technique. In group 1, a harmonic scalpel was used in 50 patients for harvesting arterial conduits (50 LITA and 50 RA). In group 2, conduits were harvested using low-voltage electrocautery. To prevent side effects of clipping, all conduits in both groups remained in perfused condition until anastomosis. A 10-mm length of conduit was cut for transmission electron microscopy investigation. We calculated duration of harvesting, blood flow changes, and histopathologic changes of the conduits according to a vessel scoring system. RESULTS: In the harmonic scalpel group, we detected pathologic findings-corruption of endothelial integrity, subendothelial damage, and endothelial pathology-in 5 specimens (10%) (3 LITA  [6%] and 2 RA [4%]). In group 2, pathologic findings were detected in 16 conduits (32%; 11 LITA, 22%, and 5 RA, 10%). Endothelial dissection, subendothelial disarrangement, cellular separation due to intercellular edema, and subadventitial hematoma were the main pathologic changes in the classic harvesting method. There was a significant difference between the groups (P = .001). Harvesting time of LITA was nearly similar in both groups: 26.9 ± 11.1 min (range 25-38) in group 1 and 21.3 ± 8.6 min (range 21-25) in group 2 (P = .049). RA harvesting time was significantly shorter with the harmonic scalpel technique (20.3 ± 3.9 versus 27.6 ± 5.4 min, P = .022). The blood flow of the conduits was similar, with no statistical difference for the 2 arterial conduits (LITA, P = .76; RA, P = .55). CONCLUSION: In the learning curve period, the use of a harmonic scalpel is time consuming and presents some difficulties during the harvesting of conduits. According to our study results, however, the harmonic scalpel technique may be useful because of decreased pathology, including spasm. In our opinion, graft occlusion or thrombus as a life-threatening condition and endothelial dysfunction may decrease with the use of this alternative harvesting technique.

Ten-Year Clinical Experience on Chylothorax after Cardiovascular Surgery.

BACKGROUND: Chylothorax or pseudo-chylothorax is a serious complication after adult and pediatric cardiac surgery. This study presents our 10-year clinical experience of chylothorax after cardiac surgery. METHODS: Between January 2008 and February 2019, 4896 cardiovascular surgeries were performed in 2 tertiary clinics, with 416 patients in the pediatric age group (8.4%). Chylothorax and pseudo-chylothorax were detected in 47 patients (22 adult and 20 pediatric patients, 4.8%). Pseudo-chylothorax was seen in 5 adult patients. In 27 patients, a pleural effusion developed on the left side (64.2%). Quantities of chylomicron in pleural effusion were significant in all patients. In addition, protein and lactate dehydrogenase levels were >2.9 g/dL. The cholesterol level in the pleural effusion was >2.49 mmol/L in all patients. The mean latency period was 8 days (range 3.1 to 63.1). For the management of chylothorax, somatostatin or octreotide as a somatostatin analog was administered in 23 patients (15 adult and 8 pediatric) in the intensive care unit. Somatostatin or octreotide was administered intravenously or subcutaneously at a dose of 0.3 to 4 µg/(kg · h-1). We used dexamethasone as a steroid combined with somatostatin in patients who were resistant to medical treatment before pleurodesis or ductus closure. Classic chemical pleurodesis combined with fibrin glue was performed in 11 patients (8 adult and 3 pediatric). Surgical duct ligation, as the last option, was performed in 7 patients. RESULTS: No mortality or morbidity was observed. Chylothorax improved with the medical approach in 23 patients within 24.2 ± 11.3 days (48.9%). We successfully performed the pleurodesis procedure using fibrin glue in addition to the classic method. The mean duration of conservative treatment was 27.1 days (range 11 to 39). After discharge from the hospital, 2 children had recurrence of chylothorax, and the ductus thoracicus was surgically ligated. No complication was seen during or after ductus ligation. CONCLUSIONS: According to our clinical experience, chylothorax is not an extremely rare complication after cardiac surgery in pediatric cardiovascular surgery. A number of patients with chylothorax may be treated medically and with diet adjustment. Medical treatment including steroid administration may be the first treatment strategy immediately after diagnosis. Classic chemical pleurodesis combined with fibrin glue may be applied in the early stages. Surgical ligation of the ductus thoracicus should be considered the last treatment option.

Early complications in ascending aortic aneurysm surgery: a single centre experience of 81 patients.

AIM: To investigate major in-hospital complications of ascending aorta reconstruction and to identify factors associated with these complications. Methods All consecutive patients admitted to our clinic for aortic aneurysm repair from June 2005 to June 2009 were enrolled in this retrospective study. Demographic data, details of the surgical procedures and major in-hospital complications were assessed and recorded from the institutional electronic database. Patients were divided into two groups according to the development of major in-hospital complications. Results The New York Heart Association (NYHA) Class of patients with major in-hospital complications was higher than those without complications. In addition, the number of patients with coronary artery disease (CAD), diabetes, chronic renal disease (CRD), chronic obstructive pulmonary disease (COPD), and previous cardiac surgery was significantly higher in those with major in-hospital complications. Moreover, the requirement for inotropic agents and intra-aortic balloon pump was higher in these patients. Cross-clamp time was significantly higher in patients with major in-hospital complications (107±34 vs. 79±26 (p<0.001). Presence of CRD (r=0.308; p=0.005) and CAD (r=0.244; p=0.028), previous cardiac surgery (r=0.266; p=0.022), cross-clamp time (r=0.349; p=0.001) and IABP requirement (r=0.308; p=0.005) were significantly correlated with the development of major in-hospital complications. Conclusion Our results show that presence of underlying CRD and CAD, previous cardiac surgery, length of cross-clamp time and IABP requirement were significantly associated with the development of in-hospital complications in patients undergoing surgical reconstruction for ascending aortic aneurysm.