Clinical comparison of potassium-titanyl-phosphate (KTP) versus neodymium:YAG (Nd:YAG) laser treatment for lower extremity telangiectases.

BACKGROUND: The Nd:YAG laser has been considered the gold standard of treatment for leg veins, but pain and side effects have fueled physicians to use treatment alternatives. OBJECTIVE: To compare the clinical efficacy of the long-pulsed 1064-nm Nd:YAG laser with KTP laser irradiation in the treatment of leg telangiectasia. METHODS: A series of 16 patients with size-matched superficial telangiectases of the lower extremities were randomly assigned to receive three consecutive monthly treatments with the long-pulsed 1064-nm Nd:YAG on one leg and 532-nm KTP laser irradiation on the other. RESULTS: For the 16 patients who completed the study, 64 leg vein sites were treated. Average clinical improvement scores were 1.94 and 1.25 for the KTP laser-treated leg and 3.38 and 3.50 for the Nd:YAG laser-treated leg with thin (≤ 1 mm) and large (1-3 mm) vessels, respectively. After the third treatment session, average improvement scores of 2.44, 1.31 and 3.75, 3.23 were given for the KTP and Nd:YAG laser-treated sides, respectively. CONCLUSION: Both the 1064-nm Nd:YAG and KTP lasers are effective in the treatment of lower extremity telangiectases. However, the KTP laser has very low efficacy with vessels larger than 1 mm and should not be elected when treating such vessels.

Surgical treatment of peripheral artery aneurysms.

INTRODUCTION: Peripheral arterial aneurysms (PAA) may rupture, cause emboli and ischemia, and local symptoms due to compression. METHODS: A total of 109 patients who underwent surgery for PAA were analyzed retrospectively, including clinical presentation, surgical procedures used, and postoperative follow-up data obtained 10 days after discharge. RESULTS: True aneurysm was present in 59 (54.1%) patients and pseudoaneurysm in 50 (45.9%). The femoral artery was the most common location. The surgical procedures used were as follows: graft interposition in 31 patients, bypass with synthetic or autologous grafts in 33 patients, aneurysm ligation in 5 patients, primary repair in 41 patients, and patch angioplasty reconstruction in 7 patients. One patient died as a result of massive hemorrhage. In four patients, amputation had to be performed. CONCLUSIONS: It is possible to prevent amputation and other complications, including mortality, during the surgical treatment of symptomatic and asymptomatic PAA.

Reduced intimal hyperplasia in rabbits via medical therapy after carotid venous bypass.

Intimal hyperplasia is a major cause of restenosis after the interventional or surgical treatment of occlusive arterial disease. We investigated the effects of clopidogrel, calcium dobesilate, nebivolol, and atorvastatin on the development of intimal hyperplasia in rabbits after carotid venous bypass surgery. We divided 40 male New Zealand rabbits into 4 study groups and 1 control group. After occluding the carotid arteries of the rabbits, we constructed jugular venous grafts between the proximal and the distal segments of the occluded artery. Thereafter, group 1 (control) received no medication. We administered daily oral doses of clopidogrel to group 2, calcium dobesilate to group 3, nebivolol to group 4, and atorvastatin to group 5. The rabbits were killed 28 days postoperatively. The arterialized jugular venous grafts were extracted for histopathologic examination. Intimal thicknesses were 42.87 +/- 6.95 microm (group 2), 46.5 +/- 9.02 microm (group 3), 34.12 +/- 5.64 microm (group 4), and 48.37 +/- 6.16 microm (group 5), all significantly less than the 95.12 +/- 9.93 microm in group 1 (all P < 0.001). Medial thicknesses were 94 +/- 6 microm (group 2), 101.5 +/- 13.52 microm (group 3), 90.5 +/- 9.69 microm (group 4), and 101.37 +/- 7.99 microm (group 5), all significantly thinner than the 126.62 +/- 13.53 microm in group 1 (all P < 0.001). In our experimental model of carotid venous bypass grafting in rabbits, clopidogrel, calcium dobesilate, nebivolol, and atorvastatin each effectively reduced the development of intimal hyperplasia. Herein, we discuss our findings and review the medical literature.

The effect of competitive flow on both the flow and the velocity in venous grafts in a bypass model.

OBJECTIVE: The term "competitive flow" defines the flow from a partially stenosed native artery that "competes" with the flow from a graft to perfuse the distal tissues. The purpose of our study is to investigate the effects of competitive flow at different degrees of stenosis at common carotid artery, in a rabbit model by measuring both the flow volume and velocity in the venous graft. METHODS: This prospective experimental study included 33 rabbits, which were divided into three groups: in Group 1, the common carotid arteries were ligated to form a total occlusion, in Group 2, the common carotid arteries were externally incompletely ligated to achieve 50% stenosis, and in Group 3, common carotid arteries were fully patent. The jugular vein was reversed and anastomosed to proximal and distal common carotid arteries using end to side anastomosis technique. Mean arterial pressure, the total flow and velocity were measured in native carotid arteries prior to surgery and in venous grafts 2 months after surgery using Doppler ultrasonography. Statistical analysis was performed using Chi-square test and Kruskal Wallis analysis of variances. RESULTS: There were no differences in graft mean velocity (Group 1--16.8+/- 6.7 cm/sec, Group 2--14.1+/- 6.1 cm/sec and Group 3--12.1+/- 6.7 cm/sec), and mean flow volume (Group 1--33.9+/- 11.5 mL/min, Group 2--29.0+/- 8.3 mL/min, and Group 3--24.4+/- 12.8 mL/min) between groups after surgery (p>0.05 for both). CONCLUSION: As it was the case in this rabbit model, the reduction of flow volume or velocity in lesser degrees of stenosis in the carotid artery venous bypass grafts is not significant in a statistical perspective. Although in short-term this effect did not create a difference for graft patencies between the groups, it may be important in long-term.

[Principles for the treatment of cardiac injuries: a twenty-two year experience]. / Kalp yaralanmalarinda tedavinin esaslari: Yirmi iki yillik deneyim.

BACKGROUND: Penetrating cardiac injuries have a rather high mortality and require a rapid diagnosis and emergency surgical intervention. The aim of this study was to present and discuss our experience with penetrating heart wounds. METHODS: Sixteen patients with penetrating cardiac injury underwent surgical treatment at the Department of Cardiovascular Surgery between 1985-2007. The patients ranged in age from 6 to 71 years (mean age 45.1 years). The cause of cardiac injury was stab wounds in 8 patients (50%), iatrogenic reasons in 6 patients (37.5%) and shotgun wounds in 2 patients (12.5%). RESULTS: Exposure to the heart was accomplished by a median sternotomy in 12 patients (75%) and a left-sided anterolateral thoracotomy in 4 patients (25%). The right ventricle (RV) was injured in 7 patients (43.75%), left ventricle (LV) in 3 patients (18.75%), left atrium (LA) in 1 patient (6.25%), LV+LA in 1 patient (6.25%), and coronary arteries in 4 patients (25%). Cardiac wounds were treated by simple suture technique over Teflon or pericardial pledgets in all patients. Two patients died in the early postoperative period. CONCLUSION: The basis for successful management of penetrating cardiac trauma is effective resuscitative measures followed by early detection and definition and emergency surgical treatment of the injury.

Successful combination of interventional and surgical treatment of left atrium perforation.

Percutaneous interventions are increasingly used in the treatment of cardiac diseases which are resistant to medical treatment. However, the complications caused by these interventions can lead to serious results. In this article, we present a case of a successful combination of interventional and surgical treatment methods, following the development of left atrial perforation during radiofrequency catheter ablation (RFA), in a patient with atrial fibrillation resistant to medical treatment.

Idiopathic true brachial artery aneurysm in a nine-month infant.

Upper extremity peripheral artery aneurysms are a rarely encountered arterial disorder. Brachial artery aneurysms seen in the pediatric age group are generally trauma resultant. A nine-month-old male infant patient presented with complaints of an asymptomatic mass in the arm. Following Doppler ultrasonography and magnetic resonance imaging (MRI) examinations, saccular aneurysm, originating from the left brachial artery was diagnosed in the patient without history of trauma. The aneurysm was resected by surgical intervention, and primary repair of the brachial artery was performed by end-to-end anastomosis. No complication was observed during the follow-up. Surgical intervention for upper extremity aneurysms should be initiated without delay in order to prevent extremity ischemia and amputation.

[A rare case of endocarditis due to Moraxella catarrhalis in an immunocompetent patient]. / Nadir görülen bir olgu: immün kompetan bir hastada Moraxella catarrhalis'e bagli endokardit.

Moraxella catarrhalis is a gram-negative, catalase and oxidase positive diplococcus. While it causes otitis media, sinusitis, bronchitis and conjunctivitis in children and adults, it has a tendency to cause lower respiratory tract infections in older ages. More severe clinical pictures with the range of sepsis to endocarditis are also seen in immunocompromised patients. In this report, a case of M. catarrhalis endocarditis in an immunocompetent host who needed valve replacement has been presented. Forty three years old female patient was admitted to our hospital with the complaints of fever, nausea, night sweating and arthralgia for 20 days. Physical examination revealed systolic murmurs on the apex, and vegetation on the atrial surface of mitral valve was detected by transthoracic echocardiography. Intravenous (IV) ampicillin (4 x 3 g/day) and gentamicin (3 x 80 mg/day) treatment was started empirically with prediagnosis of infective endocarditis. The treatment was modified to IV ceftriaxone (1 x 2 g/day) and gentamicin (3 x 80 mg/day) due to the reporting of gram-negative bacilli in blood culture (BacT/ALERT 3D, bioMérieux, France) on the next day. Gram-negative cocobacilli/diplococci were detected with Gram stain on the smear prepared from the blood culture bottle. Simultaneous subcultures to blood agar and eosin methylene blue agar yielded white colored, S-type, non-hemolytic colonies on only blood agar. Catalase and oxidase tests were positive, while beta-lactamase activity was negative. The isolate was identified as M. catarrhalis by using API NH (bioMérieux, France) identification strips. M. catarrhalis was isolated from five different blood culture specimens of the patient. The focus for bacteremia could not be detected. The patient underwent mitral valve replacement operation as an emergency since the vegetation exhibited rapid growth on the fifth day of medical treatment. Antibacterial therapy was completed for 6 weeks. Control echocardiography revealed that artificial mitral valve was open and functional, thus the patient recovered completely without sequela. In conclusion, M. catarrhalis should be considered as a possible cause of infective endocarditis even in immunocompetent patients.

The effect of preoperative circadian blood pressure pattern on early postoperative outcomes in patients with coronary artery bypass graft surgery.

OBJECTIVE: The aim of this prospective study was to evaluate the relationship between preoperative circadian blood pressure pattern and early postoperative course in patients undergoing coronary artery bypass graft (CABG) surgery. METHODS: One hundred and thirty patients planning to undergo isolated CABG operation were included to the study (80 men; 50 women). All patients were studied with ambulatory blood pressure monitoring performed 24 hours before surgery and were divided into 2 groups according with presence (79 patients) or absence (51 patients) of dipper phenomenon. Non-dippers were defined as those with a nocturnal reduction of systolic and diastolic blood pressures of less than 10% of daytime pressures. Both groups were compared with each other from the aspect of postoperative need for intraaortic balloon counterpulsation (IABP), inotropic drug support, extubation time, length of intensive care unit and hospitalization stays, renal failure, stroke, malignant ventricular arrhythmia, atrial fibrillation, postoperative myocardial infarction and cardiac mortality. Statistical analyses were performed using Chi-square, unpaired t and Mann-Whitney U tests. Logistic regression analysis was performed to establish associations of non-dipper phenomenon with the risk of postoperative complications. RESULTS: When compared with the dipper patients, need for inotropic medications (37.5% vs. 62.5%), low cardiac output syndrome (30.4% vs. 69.6%), postoperative myocardial infarction (28.6% vs. 71.4%) and malignant ventricular arrhythmias (27.8% vs. 72.2%) were higher in the non-dipper patients (p<0.05 for all). Logistic regression analysis demonstrated that non-dipper phenomenon after CABG was associated with longer cardiopulmonary bypass time (OR=1.038, 95%CI 1.016-1,060, p=0.001), more need for postoperative inotropic agent (OR=4.014, 95%CI 1.235-13,047, p=0.021) and postoperative IABP (OR=6.625, 95%CI 1.564-28.069, p=0.01) support, higher risk of low cardiac output syndrome (OR=4.159, 95%CI 0.921-18.775, p=0.064), malignant ventricular arrhythmia (OR=4.653, 95%CI 0.964-22,456, p=0.056) and postoperative myocardial infarction (OR=7.629, 95%CI 1.448-40.177, p=0.017). CONCLUSION: Dipper and non-dipper phenomenon can be used as a simple analysis tool for assessing early postoperative mortality and morbidity.

Coexistence of pulmonary embolism, aortic dissection, and persistent left superior vena cava in the same patient.

We report a patient with pulmonary embolism, dissection in the descending and abdominal aorta, and persistent left superior vena cava. To our knowledge, coexistence of these three clinical entities has never been described before in the same patient.

Inhibition of vein graft intimal hyperplasia by periadventitial application of hyaluronic acid-carboxymethyl cellulose: an experimental study.

OBJECTIVE: Placement of an external support has been reported to prevent intimal hyperplasia of vein grafts. In this study, we investigated the effect of HA/CMC on intimal hyperplasia in a rabbit model. DESIGN: Right jugular vein to common carotid artery bypass grafting was performed in 24 female New Zealand white rabbits (2.5-3.0 kg). Animals were divided into two groups: control group (n=12) and HA/CMC group (n=12). Absorbable membrane barrier was wrapped around vein grafts in HA/CMC group. In control group, no material was applied following venous graft bypass. RESULTS: At 1 month, in the vein grafts supported with the HA/CMC membrane neointimal thickening was significantly less (109 microm [IQR, 78-166]) compared to the unsupported control grafts (220 microm [IQR; 101-312]; p<0.001). Medial thickening in the HA/CMC group (128 microm [IQR, 101-181]) compared to unsheathed control grafts (182 microm [IQR, 131-255] p<0.001) was also significantly less. CONCLUSION: Periadventitial placement of HA/CMC as an absorbable membrane inhibits intimal hyperplasia of vein bypass grafts in a rabbit model.

[Transmyocardial laser revascularization]. / Transmiyokardiyal lazer revaskülarizasyon.

An increasing number of patients are found to be unsuitable for revascularization by conventional approaches to the epicardial vessels. Transmyocardial laser revascularization (TMR) is a treatment choice for patients who have refractory angina pectoris when bypass surgery or percutaneous transluminal angioplasty is not indicated. Transmyocardial laser revascularization leads to significant improvements in angina. It also improves quality of life, reduces hospital readmission rates and may improve exercise tolerance. However, the technique does not effect survival, ejection fraction, cardiac events and myocardial perfusion with nuclear studies. Further results from ongoing trials are awaited with interest.

Endothoracic papaverine application for internal thoracic artery harvest.

This study compared the effects of different methods of papaverine application on free blood flow and harvesting time of the internal thoracic artery for coronary bypass grafting. Patients were randomly divided into 3 groups of 25 each: group 1 had papaverine injected into the endothoracic tissue around the internal thoracic artery before dissection, group 2 had papaverine injected into the periarterial tissues of the internal thoracic artery pedicle, and group 3 had intraluminal papaverine applied retrogradely into the internal thoracic artery. Mean blood flow was 56.3 +/- 21.3, 21.1 +/- 13.2, and 20.9 +/- 9.1 mL x min(-1) in groups 1, 2, and 3, respectively, immediately after harvesting. Flow in group 1 was significantly better than that in groups 2 and 3. Immediately before anastomosis, mean flow was 89.8 +/- 19.1, 97.6 +/- 35.4, and 95.9 +/- 19.9 mL x min(-1) in groups 1, 2, and 3, respectively, with no significant difference among groups. Internal thoracic artery harvesting times were shorter in group 1 than in groups 2 and 3. Administering papaverine into the endothoracic fascia of the internal thoracic artery bed prior to dissection is a reliable method that facilitates rapid harvesting of the graft without causing trauma and consequent spasm.

Treatment strategies in myocardial bridging: a case report.

Myocardial bridging is one of the nonatherosclerotic causes of coronary artery disease and is characterized by muscles overlying the intramyocardial course of a major epicardial coronary artery segment, leading to systolic compression. Myocardial bridging is considered a benign condition in most cases, but has been associated with serious cardiac events such as myocardial infarction and sudden death. We discuss the case of a 63-year-old man who was admitted to our hospital with effort-induced angina, bradycardia, and left ventricular hypertrophy on electrocardiogram. On coronary angiography, we found significant myocardial bridging with total occlusion in the left anterior descending artery during systole. In patients with myocardial bridging, symptoms often manifest during exercise and with tachycardia. But it is interesting to note that our patient was bradycardic and became symptomatic with minimal effort. Thus, we thought that these emphasized its significance and affected treatment strategy.