Short-term results of chimney stent revascularization of left subclavian artery and Zone 2 thoracic endovascular aortic repair for patients with aortic dissection or transection.

Background: In this study, we present the short-term results of revascularization of left subclavian artery with the chimney technique in patients with aortic dissection or transection who underwent Zone 2 thoracic endovascular aortic repair. Methods: A total of 11 patients (6 males, 5 females; mean age: 56.4±11.5 years; range, 38 to 76 years) who underwent Zone 2 thoracic endovascular aortic repair procedure and left subclavian artery revascularization with the chimney technique between April 2017 and January 2020 in our clinic were retrospectively analyzed. All patients were followed at one, three, six months and one year with computed tomography angiography. Results: The mean follow-up was 19.7±14.5 (range, 6.3 to 45.8) months. Endoleak occurred in one (9%) patient and gutter leak occurred in three (27%) patients. The mean endoleak-free (including gutter leak) time was 19.9±5.4 (95% confidence interval: 9.36-30.34) months. No mortality occurred in any of the patients. No occlusion occurred in the chimney grafts. Conclusion: The chimney revascularization technique is an alternative to other revascularization techniques of the left subclavian artery during thoracic endovascular aortic repair.

Treatment of complex atherosclerotic femoropopliteal artery disease with a self-expanding interwoven nitinol stent: Midterm results.

OBJECTIVE: To examine the efficacy and durability of an interwoven self-expanding nitinol stent for the treatment of superficial femoral and popliteal arteries. METHOD: Consecutive patients with severely diseased superficial femoral and popliteal arteries who received SUPERA® stents were retrospectively identified.The patients were followed for 12 months by Doppler ultrasound examinations, stent roentgenograms, and estimation of Rutherford-Becker class and ankle-brachial index. RESULTS: From July 2012 to May 2014, 42 limbs in 36 patients (mean age, 61.5 ± 7.5 years; 75% male) were treated with angioplasty and primary stenting. Total occlusions were present in 14 limbs, and 63.8% had either moderate or severe calcification. The mean (±SD) lesion length was 105 mm (±28). Primary patency was 91.4% at 6 months and 85.7% at 12 months. The ankle brachial index increased from 0.57 ± 0.19 preoperative to 0.91 ± 0.12 postoperative. There was no procedural or device-related morbidity or mortality after revascularization and only one major amputation was observed on follow-up. CONCLUSIONS: Our experience shows that, Supera stents are safe and effective in our cohort of patients, with acceptable patency rates. There were no stent fractures so far even with stenting of the femoropopliteal segments. Stent design provides a viable option for high-grade obstructive disease in the femoropopliteal artery.

Transposition of basilic vein in forearm for arteriovenous fistula creation: Our mid-term results.

BACKGROUND: In this study, we aimed to present our mid-term results of basilic vein transposition in the forearm to create an arteriovenous fistula. METHODS: Between January 2015 and October 2017, a total of 21 patients (13 males, 8 females; mean age 54.2±11.3 years; range, 32 to 74 years) with an adequate basilic vein and radial arterial systems who underwent basilic vein transposition in the forearm were retrospectively analyzed. All operations were performed under local anesthesia and mild sedation. The basilic vein was harvested using a single incision from elbow joint to wrist as an in situ vein graft. If the harvested basilic vein did not extend easily to the radial artery in the wrist region, the saphenous vein was harvested to extend arteriovenous fistula tract. RESULTS: The mean follow-up was 25.3±9.8 (range, 2 to 32) months. All patients underwent arteriovenous access surgery using transposed basilic vein in the forearm. In all patients, except for two, transposed basilic vein in the forearm stayed patent during follow-up with a patency rate of 90.5%. The mean fistula maturation time was 45.2±10.7 (range, 28 to 59) days. CONCLUSION: If cephalic vein diameters are too small for arteriovenous fistula creation, basilic vein system in the medial surface of the forearm may be considered a favorable option.

Combined treatment with endovenous laser ablation and compression therapy of incompetent perforating veins for treatment of recalcitrant venous ulcers.

Objective Patients with healed venous ulcers often experience recurrence of ulceration, despite the use of long-term compression therapy. This study examines the effect of closing incompetent perforating veins (IPVs) on ulcer recurrence rates in patients with progressive lipodermatosclerosis and impending ulceration. Methods Patients with nonhealing venous ulcers of >2 months' duration underwent duplex ultrasound to assess their lower extremity venous system for incompetence of superficial, perforating, and deep veins. Endovenous laser ablation (EVLA) of perforating veins was performed on patients with CEAP 6 disease with increasing hyperpigmentation, lipodermatosclerosis, and/or progressive malleolar pain. A minimum of 2 months of compressive therapy was attempted before endovenous ablation of IPVs. Demographic data, risk factors, CEAP classification, procedural details, and postoperative status were all recorded. Results Forty ulcers with 46 associated IPVs were treated with EVLA in 36 patients with CEAP 6 recalcitrant venous ulcers. Treated incompetent perforator veins were located in the medial ankle (85.7%), calf (10.7%), and lateral ankle (3.5%). Endovenous laser ablation was successful in 76% (35/46) with the first laser treatment of incompetent perforator veins and 15.2% (7/46) additional ablation procedures were performed. Of the 46 treated IPVs, 42 (91.3%) were occluded on the duplex examination at 12 months. The average energy administrated per perforating vein treated was 162 joule. Two patients reported localized paresthesia, which subsided spontaneously, but no deep venous thrombosis or skin burn was observed. Conclusion Especially in the case of liposclerotic or ulcerated skin in the affected region, PAP of IPVs is highly effective, safe, and appears to be feasible. Patients with active venous ulcers appear to benefit from EVLA of incompetent perforators in order to reduce the risk of ulcer recurrence.

The relationship between HbA1c & atrial fibrillation after off-pump coronary artery bypass surgery in diabetic patients.

OBJECTIVE: Diabetes mellitus is recognized as a risk factor for mortality and morbidity after coronary bypass grafting. We aimed to determine the association between preoperative hemoglobin HbA1c and AF after isolated off-pump coronary bypass grafting (OPCAB). METHODS: The seventy-two diabetic patients undergoing isolated off-pump coronary bypass grafting were retrospectively analyzed for AF. They were divided into; Low (4.8-5.4%), Medium (5.5-8%) and High (8.1-11.5%) groups. The three groups were compared with respect to demographic, echocardiographic, intraoperative and postoperative clinical characteristics correlation. RESULTS: Three patients died during postoperative period. AF occurred in 12 patients (16.6%) after surgery. The incidence of postoperative AF was 15.3% in the lower, 4.4% middle and 57.1% upper group. There was statistically significant correlation between preoperative HbA1C and preoperative stroke, preoperative MI history, Left atrial (LA) size, preoperative levosimendan, preoperative clopidogrel, postoperative AF, postoperative dopamine and dobutamine use, IABP, duration of extubation time, 24-hour chest tube drainage, duration of ICU and hospital mortality. Univariate logistic regression analysis showed significant correlation between postoperative AF and variables like preoperative HbA1c levels, LVEF<30%, history of preoperative MI, preoperative use of levosimendan, preoperative use of clopidogrel, postoperative dopamine, dobutamine adrenaline use, left atrium size, 24-hour chest tube drainage and length of stay in the intensive care unit. CONCLUSION: Preoperative HbA1c levels could predict the occurrence of postoperative AF in diabetic patients and may entail to administer protective strategies.

Efficacy of intralesional recombinant human epidermal growth factor in chronic diabetic foot ulcers.

OBJECTIVE: The aim of this study was to explore the clinical effects of intralesional administration of an epidermal growth factor (EGF) up to complete wound closure. METHODS: Seventeen diabetic patients with full-thickness lower extremity ulcers of more than 4 weeks of evolution were enrolled in the study. Mean ulcer size was 15.5 +/- 7.5 cm(2). Intralesional injections of 75 µg of Heberprot-P three times per week for 5-8 weeks were given up to complete wound healing. RESULTS: Full granulation response was achieved in all patients in 32.4 +/- 6.6 days. Complete wound closure was obtained in 16 (94.1%) cases in 53.1 +/- 4.7 days. The most frequent adverse events were burning sensation, tremors, chills and pain at the site of administration. After 1-year follow-up, only one patient relapsed. CONCLUSIONS: Intralesional EGF administration up to complete closure can be safe, effective and suitable to improve healing of chronic diabetic foot ulcer (DFU).

U-vein compressor improves early haemodynamic outcomes in radiocephalic arterio-venous fistulae in under 2-mm superficial veins.

AIM: In this study, we sought to determine the early postoperative results of arterio-venous fistulae (AVF) created by U-vein compressors with veins between 1.5 and 2 mm in size. METHODS: Pre-operative venous mapping was done. The fistula tract was marked at 0-, 4-, 8- and 12-cm points; 0 cm was the estimated point where the anastomosis would be done. With Doppler ultrasonography, transverse diameters in the estimated fistula tract were measured at the 0-, 4-, 8- and 12-cm points. A superficial vein that would be used as the fistula tract was dilated using U-vein compressors. In the first postoperative hour, the flow in the anastomosis, and the transverse diameter of the fistula tract at the 0-, 4-, 8- and 12-cm points were measured by Doppler ultrasonography. RESULTS: Forty patients were included in the study. U-vein compressors were used for 20 patients. Postoperative expansion of vein diameters and postoperative flow velocities were found to be statistically significantly different in patients where a U-vein compressor had been used (p < 0.001). CONCLUSION: We present a technique to dilate veins that are between 1.5 and 2 mm in diameter, which are generally accepted as poor vessels to create radiocephalic arteriovenous fistulae.

Efficacy of rotational thrombectomy on the mortality of patients with massive and submassive pulmonary embolism.

BACKGROUND: Pulmonary embolism (PE) associated with hemodynamic instability has exceedingly high mortality. We describe our experience using percutaneous mechanical thrombectomy (PMT) in patients with massive PE (MPE) and submassive PE (SPE). METHODS: Thirty-six patients (16 males and 20 females; mean age, 51.4 ± 6.6 years) with massive and submassive PE were treated with PMT. All patients exhibited acute symptoms and computed tomography evidence of large thrombus burden and evidence of right ventricular (RV) dysfunction and/or failure. An Aspirex® percutaneous aspiration device was used in all patients. Clinical outcomes, hemodynamic recovery, RV and pulmonary artery pressures (PAP), blood gas changes, thrombus clearance, and complications were evaluated. RESULTS: Treatment of 36 patients resulted in complete thrombus clearance (≥ 90%) in 83.3% of the patients (n = 30) and near-complete (50% to 90%) clearance in 13.8%. Measurements before and after treatment showed a decrease in mean PAP (53 ± 5.8 mmHg versus 25.6 ± 6.3 mmHg in MPE group [p < 0.01] and 46 ± 7.7 versus 22 ± 3.6 in SPE group [p < 0.01]). One patient died from refractory shock. No cardiovascular deaths or recurrent PE were documented during clinical follow-up but one patient demonstrated evidence of mild cor pulmonale. CONCLUSIONS: This study demonstrates safety and effectiveness of percutaneous mechanical aspiration thrombectomy in patients with massive and submassive PE with a large thrombus burden.

Levosimendan effect on spinal cord ischemia-reperfusion injury following aortic clamping.

BACKGROUND AND AIM OF THE STUDY: The new calcium sensitizer, levosimendan, not only acts as a positive inotropic agent but also, vasodilates both venules and arterioles. The aim of this experimental study was to investigate whether levosimendan has protective effects on spinal cord ischemia-reperfusion injury. MATERIAL AND METHODS: Twelve New Zealand rabbits were enrolled in this study. In addition to the control group, levosimendan is administered to the experimental group with a loading dose of 12 microg/kg prior to ischemia over a 10-minute period, followed by an infusion of 0.2 microg/kg/min during the ischemia period (30-minutes). Following the neurologic evaluation at the 24th hour of reperfusion, lumbar spinal cords were removed in order to perform microscopic examination and malondialdehyde (MDA) and myeloperoxidase (MPO) measurements. RESULTS: The mean Tarlov score of the levosimendan group (3.25) was higher than the control group (0.7) (p< 0.05). MDA level was found significantly lower in the levosimendan group when compared with the control group as 1.6 +/- 0.4 nmol/gr and 189.3 +/- 43.6 nmol/gr respectively (p < 0.05). MPO level was also found statistically significant when we compared levosimendan group with the control group. It was calculated as 11.3 +/- 1.0 micro/gr tissue and 39.1 +/- 16.9 micro/gr in the levosimendan and the control groups (p< 0.05). Light microscopic examination was carried out with tissue samples in the 24th hour of the reperfusion. Levosimendan group had better preservation with the microscopic appearance with respect to the control group. CONCLUSION: Levosimendan exhibits an important protection by means of neurological outcome, histopathological, and biochemical analysis for the ischemia-reperfusion injury of the spinal cord following the aortic clamping.

How DMSO, a widely used solvent, affects spinal cord injury.

The aim of this experimental study was to investigate whether dimethylsulfoxide (DMSO) has protective effects on spinal cord ischemia-reperfusion (I/R) injury. New Zealand rabbits were enrolled in the study. In addition to the control group, the study group received 0.1 mL/kg DMSO prior to ischemia. Blood samples were taken to obtain nitrite-nitrate levels during the surgical procedure. After neurological evaluation at 24 hr of reperfusion, lumbar spinal cords were removed for electron microscopic evaluation and malondialdehyde and myeloperoxidase measurements. The mean Tarlov score of the DMSO group was higher than that of the control group. Electron microscopic examination was carried out with tissue samples at 24 hr of reperfusion. The DMSO group had better preservation with the electron microscopic scoring compared to the control group. Malondialdehyde and myeloperoxidase levels were decreased in the DMSO group compared to the control group. Nitrite-nitrate levels were also lower in the DMSO group compared to control at 5 and 30 min of reperfusion. This study demonstrates a considerable neuroprotective effect of DMSO on neurological, biochemical, and histopathological analyses during periods of spinal cord I/R injury in rabbits. Although there was a difference between the DMSO and control groups in all measured parameters in our study, this was not statistically significant. DMSO deserves further investigation related with spinal cord ischemia and reperfusion. We should also consider the effect of DMSO when we use it as a solvent or vehicle during experimental I/R models.

Evaluation of hemodynamic changes in patients with mitral valve replacement using dobutamine stress echocardiography.

OBJECTIVE: The aim of this study was to investigate the response of heart to stress according to the size of the prosthetic valve in patients who had undergone mitral valve replacement by using dobutamine stress echocardiography (DSE) and to evaluate the relationship between the size of the prosthetic valve and cardiac recovery-remodeling process. METHODS: Thirty-nine patients, who had undergone mitral valve replacement were compared in terms of left ventricular diameters, systolic functions and cardiac mass indexes in order to investigate the effect of the mechanical valve size on postoperative cardiac remodeling in this longitudinal study. They were divided into three groups according to their valve size: Group 1 (valve size<29 mm, n=11), Group 2 (valve size=29 mm, n=11) and Group 3 (valve size>29 mm, n=17). Statistical analysis was performed using Chi-square and one-way ANOVA tests to determine the statistical differences between the groups. The repeated measurements of two-way ANOVA test was used to analyze effects during long-term follow-up. RESULTS: Only Group 1 patients achieved a significant decrease in terms of left ventricular mass index and end-diastolic diameter (138.3+/-29.7 g/m2 vs 86.6+/-15.6 g/m2 and 5.1+/-0.5 cm vs. 4.4+/-0.4 cm, p<0.05). Group 3 patients' left ventricular ejection fraction become worse after the operation (64.0+/-5.6% vs. 55.9+/-6.5%, p<0.05). Maximum and mean pressure gradients across the mitral prosthesis as well as pulmonary artery pressure were significantly increased in all groups during DSE. Maximum gradients increased from 14.2+/-4.6 to 20.7+/-7.5 mmHg in Group 1 (p<0.05), 11.6+/-4.7 to 16.2+/-6.8 mmHg in Group 2 (p<0.05), and 10.6+/-3.1 to 20.8+/-12.7 mmHg in Group 3 (p<0.05). Isovolumic relaxation time decreased in all groups following the dobutamine infusion, as expected, but this decline was not significant in Group 3. CONCLUSION: A worsening in left ventricular systolic function was observed in large- sized valve prosthesis group. Only the patients who had undergone MVR with small-sized valve prosthesis achieved a decrease in cardiac mass index and preservation of the systolic function. The echocardiographically determined differences and mass index that appeared after the operation may point out that, the effect of the operation on cardiac remodeling can be related with the ventricular size.

Coronary atherosclerosis distribution and the effect of blood glucose level on operative mortality/morbidity in diabetic patients undergoing coronary artery bypass grafting surgery: a single center experience.

OBJECTIVE: The study aim was to investigate the effect of blood glucose level on atherosclerotic lesion distribution and the contribution to the operative mortality/morbidity in diabetic patients who underwent coronary artery bypass grafting (CABG). METHODS: Between 1986-2003, a total of 2095 patients with diabetes mellitus underwent CABG. The analysis was carried out retrospectively from the clinical records. The patients were divided into four groups according to the blood glucose levels that were obtained when they first applied to hospital; Group 1 (492 patients with blood glucose < 120 mg/dl), group 2 (1112 patients with blood glucose - 120-200 mg/dl, group 3 (261 patients with blood glucose 201-250 mg/dl) and group 4 (230 patients with blood glucose > 250 mg/dl). One way ANOVA test was used for the statistical analysis of continuous variables and Chi-square test was used for analyzing the categorical variables. RESULTS: Emergent operation rate due to acute ischemia gradually increased from Group 1 to Group 4 and reached 6.6% in Group 4 (p=0.005). Operation time and the duration of cardiopulmonary bypass and cross clamp were significantly longer in patients with high blood glucose levels (p<0.05). Necessity for inotropic drug administration postoperatively (p<0.05) and mechanical support (p<0.05) were significantly higher also. The hospital mortality in group 3 was 9.6% and in group 4 was 11.3% (p=0.09). No statistically significant difference was found in terms of morbidity between the groups (p>0.05). The multi-vessel coronary artery disease was more common in groups with high blood glucose level (p<0.05). As the blood glucose level raised, patients were more frequently (p<0.05) confronted with distal left anterior descending artery, middle circumflex artery and right coronary artery lesions. CONCLUSION: Uncontrolled blood glucose level not only increased the perioperative complications but also the incidence of middle and distal coronary artery lesions. It is necessary to diagnose and aggressively treat the high blood glucose level especially before the CABG.

In which period of injury is resveratrol treatment effective: ischemia or reperfusion?

The periods of ischemia and reperfusion represent different characteristics by lack of oxygen and reoxygenation. The aim of this experimental spinal cord injury model was to investigate whether resveratrol has protective effects during ischemia or reperfusion and the mechanism of the protection by using N-nitro-L-arginine methyl ester (L-NAME), an inhibitor of nitric oxide synthase. Rabbits were divided into seven groups according to the time of administration of resveratrol or L-NAME (RI and RR, resveratrol during ischemia or reperfusion; IL and RL, L-NAME during ischemia or reperfusion; RILR, resveratrol during ischemia and L-NAME during reperfusion; LIRR, L-NAME during ischemia and resveratrol during reperfusion; control group). After neurologic evaluation at the twenty-fourth hour of reperfusion, lumbar spinal cords were removed for electron microscopic evaluation, immunohistochemical staining for apoptosis, and malondialdehyde (MDA) and myeloperoxidase (MPO) measurements. The RILR group had the best functional recovery, with a mean 3.6 Tarlov score (P < 0.05), and showed near normal electron microscopic findings (scores of 7.6 +/- 0.9 for the control group and 3.9 +/- 2.9 for the RILR group, P < 0.05). MPO and MDA levels were decreased in all groups compared with the control group, but only the decrement in the RILR group reached statistical significance. Immunohistochemical analysis showed that the groups including resveratrol and L-NAME together had the best staining for apoptosis. Resveratrol exhibits important protection by means of neurologic outcome, histopathologic analysis, and biochemical analysis, especially when used in during ischemia followed by L-NAME administration during reperfusion. Also, resveratrol protects against apoptosis, especially when combined with L-NAME.

Mechanical heart valve prosthesis in the pulmonary position without anticoagulation: case report.

A 10-year-old girl underwent tetralogy of Fallot (TOF) repair and subsequent pulmonary valve replacement with a St. Jude Medical mechanical heart valve prosthesis. Valve replacement was necessary due to right heart failure resulting from pulmonary regurgitation occurring three months after TOF repair. At the age of 25 years, when she became pregnant, routine cardiac evaluation indicated that she had not used oral anticoagulation during the past 15 years. The patient was of rural origin, and of poor socioeconomic status, but is currently in her 15th postoperative year, with neither clinical problems nor any sign of valve failure.