Results of endovascular treatments of Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease involving the aortic bifurcation.

Objectives: The current study aims to report midterm results of patients treated with endovascular intervention, kissing stent, or covered endovascular reconstruction of the aortic bifurcation, for Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease involving the aortic bifurcation. Methods: Eighteen patients who have intermittent claudication or chronic limb threatening ischemia with Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease involving the aortic bifurcation enrolled to the study between January 2018 and January 2021. Kissing stents, Advanta V12 (Atrium, Getinge Group), were used in 13 patients, and the covered endovascular reconstruction of the aortic bifurcation technique was used in 4 patients to reconstruct the aortic bifurcation. The patients were followed for a median of 49 months (min. 2, max.58 months). Patency rates, mortality, morbidities, and reinterventions were recorded. Results: The mean age of the patients was 60.4 ± 10 years. Technical success was achieved in 94.4% of the patients, but one patient had to convert to open surgery. Primary patency rate of the remaining patients was 85.6% at 58 months. Target lesion revascularization rate was 11.7%. One patient had successful reintervention for in stent restenosis, and secondary patency rate was 93.3% at 58 months. Limb salvage rate was 84.6% during the follow-up. Two patients had myocardial infarction (11.1%) and one mortality (5.6%) occurred because of cerebrovascular event in the follow-up. Conclusions: Endovascular techniques can be used safely for reconstruction of the aortic bifurcation in Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease in selected patients who have high risk for open surgery. Covered endovascular reconstruction of the aortic bifurcation is the only technique that showed patency rates approaching open surgery in treatment of aortoiliac occlusive disease involving the aortic bifurcation to date. Although promising patency results were achieved with kissing-covered stents, long-term patency rates were still lower than those achieved with open surgery. Further randomized controlled studies comparing the long-term results of these techniques are needed.

Genes predisposing tunneled catheter thrombosis in hemodialysis patients.

Background: This study aims to investigate the association of genes predisposing thrombophilia with tunneled catheter thrombosis in hemodialysis patients. Methods: Between October 2018 and December 2020, we compared the frequencies of genetic polymorphisms causing thrombophilia, including prothrombin G20210A, factor V Leiden, methylene tetrahydrofolate reductase (MTHFR) C677T, MTHFR A1298C, plasminogen activator inhibitor (PAI), factor XIII V34L and clinical characteristics of 52 patients with a history of 2 tunneled2 tunneled catheter thrombosis occlusions within a year (Group 1; 24 males, 28 females; mean age: 62±8.9 years; range, 45 to 77 years), 52 patients who underwent their first tunneled catheter thrombosis insertion (Group 2; 29 males, 23 females; mean age: 63±15.2 years; range, 22 to 87 years), and 51 healthy controls (Group 3; 26 males, 25 females; mean age: 34±9.2 years; range, 19 to 54 years). Results: Groups 1 and 2 carried the MTHFR A1298C (p=0.048) and compound heterozygous MTHFR A1298C and C677T (p=0.048) polymorphisms more frequently than Group 3. However, subgroup analysis results were not statistically significant. The other polymorphisms were distributed similarly in all three groups. The MTHFR polymorphisms had a weak effect on tunneled hemodialysis catheter thrombosis in neural network analysis. Conclusion: Our study results indicated that there was a concomitance of MTHFR polymorphisms with hemodialysis-dependent chronic kidney disease. The MTHFR A1298C and compound heterozygous MTHFR polymorphisms may be associated with tunneled hemodialysis catheter thrombosis. Thrombophilia gene screening may be recommended in hemodialysis patients undergoing tunneled hemodialysis catheter thrombosis at least twice in a year.

Efficacy and cost-effectiveness of cell saver usage in the repair of thoracic aortic aneurysms and dissections.

INTRODUCTION: A substantial amount of blood loss occurs during the open repair of aortic aneurysms or dissections. The aim of the present study is to determine the efficacy and cost-effectiveness of cell saver devices in blood conservation during the open repair of thoracic aortic pathologies. METHODS: The present study prospectively collected the data pertaining to 25 patients who underwent surgical management of thoracic aortic aneurysms or dissections using a cell saver (Group 1, n = 25). The volume and cost of transfusion and postoperative outcomes were compared with the second group of patients who underwent surgery without the use of cell savers in the previous year (Group 2, n = 25); the data pertaining to the same were retrospectively collected from the hospital records. The patient characteristics and categorical variables were compared using the x2 test and Fisher's exact test. Transfusion volume and costs were compared using the independent samples t-test and Mann-Whitney U test. RESULTS: The patients in both the groups displayed similar characteristics and risk factors. The total volume of allogenic red blood cell (p < 0.001) and total blood product (p = 0.01) transfusions were significantly lower in Group 1. The cost of red blood cell (p < 0.001) and total transfusions (p = 0.03) were lower in Group 1. The two groups displayed similar in-hospital morbidity and mortality rates. CONCLUSIONS: There was a significant association between the use of cell savers and the decreased need for red blood cell and total blood product transfusions. Considering the cost of the cell saver set, transfusion costs in the two groups were comparable.

Thromboelastogram reduces blood use by inspecting coagulation in heart surgery.

OBJECTIVE: Blood transfusion after coronary artery bypass surgery is carried out according to general coagulation tests and blood counts. Our aim was to determine the effects of rotational thromboelastography results on the amount of blood products used in the intraoperative and postoperative periods in coronary artery bypass patients. METHODS: Our study included 164 patients who underwent coronary artery bypass. A control group was formed from 82 patients picked from hospital records, who had elective coronary artery bypass before the introduction of rotational thromboelastography in our clinic. Blood transfusion was performed in this group according to conventional laboratory data. The study group comprised 82 patients who had elective coronary artery bypass after the introduction of rotational thromboelastography. Blood transfusion was performed in the study group according to rotational thromboelastogram results. The amounts of blood products used in the 2 groups were compared. RESULTS: There were statistically significant decreases in the intraoperative and postoperative amounts of packed red blood cells (p = 0.012 and p = 0.006) and postoperative whole blood (p = 0.013) used in the study group compared to the control group. Postoperative bleeding was also significantly reduced (p = 0.001) in the study group. CONCLUSION: Blood transfusion is an important issue after coronary artery bypass, and because of the decreased amount of blood products used, a rotational thromboelastography-based blood transfusion algorithm should be applied in patients undergoing coronary artery bypass.

Is "Attenuation of Oxidative Stress" Helpful to Understand the Mechanism of Remote Ischemic Preconditioning in Cardiac Surgery?

OBJECTIVES: The aim of this study was to determine the effect of remote ischemic preconditioning (RIPC) on markers of cardiac ischemia and response to oxidative stress in patients undergoing coronary artery bypass grafting (CABG) surgery. DESIGN: A prospective, randomized, and blinded study. SETTING: A single-center university hospital. PARTICIPANTS: This study included patients who underwent isolated CABG surgery with cardiopulmonary bypass who were selected carefully to prevent confounding with factors known to affect markers of ischemia-reperfusion and response to oxidative stress. INTERVENTIONS: The authors randomly assigned patients to RIPC to the left lower extremity using a blood pressure cuff (study group) or a cuff that was applied but not inflated or deflated (control group). MEASUREMENTS AND MAIN RESULTS: At 6 hours after CABG surgery, high-sensitivity cardiac troponin T levels were significantly lower in the study group than in the control group. Levels of superoxide dismutase, an antioxidant enzyme, were significantly greater 15 minutes after release of the cross-clamp in the study group, whereas malondialdehyde levels were lower (not significantly) at 1 and 15 minutes after release of the cross-clamp. Hemodynamic parameters were not significantly different at any time point during the study. CONCLUSIONS: The authors' method of RIPC before CABG surgery resulted in less myocardial ischemia, as indicated by lower troponin levels. Changes in levels of endogenous antioxidant enzymes supported the hypothesis that this protection from ischemia-reperfusion injury was related to scavenging of free oxygen radicals. Future studies might include a more heterogeneous population and medications that lower the body's response to oxidative stress.

Is genetic screening necessary for determining the possibility of venous thromboembolism in cancer patients?

OBJECTIVE: To determine the risk of an association with some genetic polymorphisms involved in venous thromboembolism (VTE) gene variations (FVL, FV H1299R, FII G20210A, MTHFR C677T, MTHFR A1298C, PAI-1 4G/5G, ß-fibrinogen -455 G → A, FXIII Val34Leu and GpIIIa HPA-1a) in cancer patients. SUBJECTS AND METHODS: Among 78 cancer patients, 28 who had proven first episode of VTE were selected as the patient group, with 50 control samples selected from age-, sex- and body mass index-matched healthy volunteers (healthy group). The differences in frequency of genetic polymorphisms were found to be statistically insignificant between these two groups. RESULTS: Logistic regression analysis after adjustment for age, sex, smoking and hypertension showed no difference. The screened mutations of these genes were not significantly associated with VTE risk. CONCLUSION: There is no possible benefit from genetic screening tests regarding VTE in cancer patients.

Unusual location of hydatid cyst: the posterior leaflet of tricuspid valve.

Hydatid Cyst disease involves the heart in 0.02-2% of the cases. It can appear with symptoms very similar to coronary artery disease, cardiac valvular disease and pericarditis. We present a case of hydatid cyst that was located on the posterior tricuspid leaflet and that caused tricuspid regurgitation in 37 year old female patient who has gone through hydatid cyst excision from the bilateral lungs with median sternotomy 2 years ago. In addition to the right atrial and ventricular dilatation, second degree tricuspid regurgitation and significant pulmonary hypertension was found. The 2 x 2 cm smooth surfaced mass was resected from the posterior leaflet of the tricuspid valve and the defect was closed with suture with the aid of cardiopulmonary bypass. The patient followed with long term albendazole treatment. Cardiac echinococcosis should be kept in mind in some patients throughout their life with a history of previous hydatid cyst disease. Surgical excision without rupture is the treatment of choice for cardiac hydatid cyst, with following medical therapy in order to prevent recurrence.

Superior mesenteric artery branch--jejunal artery aneurysm.

Visceral artery aneurysm (VAA) is a relatively uncommon disorder and it shows some vague symptoms. Therefore, the clinical diagnosis is difficult and these aneurysms are discovered and diagnosed only after rupture in many cases. This case report describes the history of a woman who had a superior mesenteric artery (SMA) branch aneurysm. A 62-year-old woman presented with fatigue and moderate to severe epigastric and mid-back pain. A computed tomography of the abdomen and pelvis demonstrated a partially thrombosed aneurysm (38×40 mm) rising from the jejunal branch of the SMA. The aneurysm which contains mural thrombus is resected, and a saphenous vein graft interposition is performed between the ends of the same jejuno-jejunal artery. The patient's recovery was unremarkable, and she was discharged on postoperative day 7. Rapid diagnosis, localization, and surgical or endovascular interventions are necessary to avoid devastating consequences in VAAs. Saphenous vein graft interposition is a good choice for surgical intervention for patients not suitable for endovascular treatment.

Left ventricle perforation and pseudoaneurysm with an unusual presentation of a patient with stomach ache. Case report.

A 49-year-old man admitted with a 3 weeks history of stomachache and without any cardiac symptoms and diagnosed as pseudoaneurysm of the left ventricle is reported. The repair was performed with the aid of cardiopulmonary bypass, defect was repaired with Gore-tex patch and myocardial tissues were approximated and closed by using two Teflon stripes. BioGlue was applied on the sutures and between the stripes. We report this unusual case because rarity and high clinical index of suspicion is needed to make correct diagnosis in such patients. Although there is a significantly high mortality of the pseudoaneurysm cases their repair can and should be performed as an urgent procedure.

Trimetazidine may protect the myocardium during cardiac surgery.

BACKGROUND: Trimetazidine is an anti-ischemic agent with cardioprotective effects. The purpose of this double-blind, controlled, prospective randomized study was to investigate the possible effects of the preoperative use of trimetazidine on the biochemical markers of myocardial injury during open heart surgery and to determine if it has any myocardial protective effects. METHODS: Thirty patients undergoing coronary artery bypass grafting surgery, received either trimetazidine (study group, n = 15) or not (control group, n = 15). Pretreatment began 2 weeks before the operation with trimetazidine (60 mg/day orally), and the control group received no medication. We measured the levels of serum creatine kinase (CK), CK isoenzyme MB (CK-MB), myoglobin, and troponin T in venous blood samples obtained before and after the operation to evaluate the effect of this drug against myocardial damage. We also took serial blood samples from the radial artery and the coronary sinus before the institution of cardiopulmonary bypass (CPB) and at 2 and 15 minutes after the removal of the cross-clamp to measure lactate levels and calculate the lactate extraction of the myocardium. RESULTS: Postoperative levels of myoglobin, troponin T, CK, and CK-MB were significantly lower in the trimetazidine group than in the control group (P < .05). There was also a significant difference in the values for the lactate extraction calculation between the groups at minute 2 after the removal of the cross-clamp (P < .05). CONCLUSION: We conclude that pretreatment with trimetazidine has some beneficial effects in protecting the myocardium and decreasing myocardial injury during the cardioplegic arrest period in open heart surgery without affecting postoperative hemodynamics.

Preoperative oral pentoxifylline for management of cytokine reactions in cardiac surgery.

BACKGROUND: Cardiopulmonary bypass may lead to many inflammatory responses that may cause myocardial dysfunction after open heart surgery. We aimed to investigate the effect of preoperative pentoxifylline treatment to reduce the occurrence of cardiopulmonary bypass-induced inflammatory response. METHODS: In a prospective, randomized study, 40 patients undergoing coronary artery bypass graft surgery received either pentoxifylline (study group, n = 21) or not (control group, n = 19). Pretreatment with pentoxifylline (800 mg/day orally) was started 5 days before the operation. Blood samples for measurements of tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, IL-8 from the arterial line, and venous blood samples for creatine kinase (CK) and CK isoenzyme fraction MB (CK-MB) were taken in both groups at 5 different time points. Hemodynamic parameters were measured with the thermodilution technique. RESULTS: TNF-alpha, IL-6, and IL-8 plasma levels increased in both groups after cardiopulmonary bypass, with a greater increase in the control group (P < .05). There were no significant differences between the groups for the values of CK-MB and hemodynamic parameters. CONCLUSIONS: We conclude that pretreatment with oral pentoxifylline before cardiac surgery inhibits proinflammatory cytokine release caused by cardiopulmonary bypass and has some beneficial effects in protecting the myocardium during the cardioplegic arrest period in open-heart surgery, without affecting postoperative hemodynamics.

Sleep disturbances after cardiac surgery with or without elevated S100B levels.

OBJECTIVE: The aim of the study was to investigate sleep disturbances of cardiac surgery patients with or without elevated S100B levels. METHODS AND RESULTS: Twenty-two patients with serum S100B > 0.3 microg/l (study group) 12 hours after cardiac surgery with cardiopulmonary bypass and 23 patients with serum S100B < 0.3 (control group) were investigated in a prospective study. They were evaluated with the use of objective sleep tests. Cardiopulmonary bypass has negatively affected the sleep characteristics in the postoperative period for both groups. Maintenance wakefulness test, total sleep time, total activity score and sleep efficiency scores were significantly shorter in the study group in the postoperative period. Sleep latency, percentage of wakefulness after sleep onset, daytime napping episodes and total nap duration in the same period were significantly higher than in the control group. CONCLUSION: Cardiac surgery affects a patient's sleep characteristics. Patients with elevated S100B values have more sleep disturbances after cardiac surgery than patients with normal S100B values.

An uncommon cause of pulsation on the left side of the thorax. Case report.

A 70-year-old man affected by clinical findings of congestive heart failure eight months after aneurysmectomy of a true left ventricular aneurysm, presented with actual pseudoaneurysm of the left ventricle. There was a 5 x 5 cm soft tissue mass on the left side of the chest, synchronously pulsating with heart beating. The repair was performed with the aid of cardiopulmonary bypass. Myocardial tissues were approximated and closed by using two Teflon stripes. BioGlue was applied on the sutures and between the stripes. Although there is a significantly high mortality of the pseudoaneurysm cases their repair can and should be performed in an urgent procedure.