Pleiotropic effects of pitavastatin: a pilot study using the saphenous vein endothelial cell model of endothelial injury and prevention of atherosclerosis.

OBJECTIVE: Cardiovascular diseases are responsible for the majority of deaths on a global scale. Atherosclerosis is the main risk factor for cardiovascular disorders and represents a complex phenomenon associated with endothelial dysfunction and inflammation. Statins, especially atorvastatin (ATV) and pitavastatin (PTV), are common agents used to control ongoing atherosclerotic events in the body to minimize cardiovascular disease-based deaths. MATERIALS AND METHODS: The present study aimed at comparing the efficacy of ATV and PTV in a cell line model of inflammation. Human saphenous vein cells were treated with TNF-alpha to mimic atherosclerotic conditions, and the cells were divided into 7 groups, including control, DMSO, TNF-alpha (10 ng/mL-6 hours), ATV (50 µM/24 hours), PTV (2 µM/24 hours), ATV (50 µM/24 hours)+TNF-alpha (10 ng/mL-6 hours) and PTV (2 µM/24 hours)+TNF-alpha (10 ng/mL-6 hours). The expression levels of 20 proinflammatory cytokines and chemokines were investigated in these groups using a human atherosclerosis antibody array. RESULTS: Possible pathway interactions were determined by STRING and PANTHER analyses. Comparison with the effect of ATV indicated that PTV reduced the levels of 4 proinflammatory cytokines: CCL11, CSF2, CCL20, and TGFB1 (p<0.05). CONCLUSIONS: Pleiotropic effects of pitavastatin against cardiovascular diseases appeared to be better; however, additional studies are required to compare statins and to identify new drugs that maintain broader protection from the risks of cardiovascular diseases.

Neutrophil-to-lymphocyte ratio as a diagnostic biomarker for the diagnosis of acute mesenteric ischemia.

PURPOSE: Due to the diagnostic challenges and dreadful consequences of delayed treatment of acute mesenteric ischemia (AMI), a variety of diagnostic markers have been previously studied. However, the diagnostic value of neutrophil-to-lymphocyte ratio (NLR), which has been suggested to be a predictor of inflammation, has never been studied for AMI. METHODS: The data of 70 patients who underwent laparotomy (n = 8) and/or bowel resection (n = 62) for AMI (n = 70) between January 2009 and March 2014 were retrospectively analyzed. To investigate the studied parameters' role in the differential diagnosis of AMI, control groups were selected from most common reasons of inflammation-related emergent surgery, acute appendicitis (AA, n = 62) and normal appendix (NA, n = 61). White blood cell (WBC), red cell distribution width (RDW), NLR and mean platelet volume (MPV) values were recorded. Outcome variables of the study were defined as diagnostic and prognostic role of NLR in AMI. RESULTS: RDW and NLR values were found to be higher in the AMI group than the AA group (p < 0.001 and p < 0.001). Also, WBC and MPV values were higher in the AMI group than the NA group (p = 0.001 and p < 0.001). Combined sensitivity, specificity, positive predictive value and negative predictive value of RDW and NLR for recommended cut-off values were 69.4, 71.2, 57.8 and 80.4 %, respectively. CONCLUSION: High NLR value (>9.9) seems to be a valuable diagnostic marker of acute mesenteric ischemia. Combined use of NLR, RDW and other clinical assessment, could help the diagnosis of AMI, especially in the absence of advanced imaging modalities and expert radiologic interpretation.

MID TERM RESULTS AFTER OPEN HEART SURGERY IN HEMODIALYSIS PATIENTS AWAITING KIDNEY TRANSPLANT: DOES CARDIOVASCULAR SURGICAL INTERVENTION PRIOR TO TRANSPLANTATION PROLONG SURVIVAL?

The aim of this study was to compare the mid and long term postoperative outcomes between the hemodialysis-dependent patients awaiting kidney transplantat who underwent open heart surgery in our department during the last five years, and those who did not receive a renal transplant, to determine the predictors of mortality, and assess the possible contribution of post heart surgery kidney transplantation to survival. The patients were separated into two groups: those who underwent a transplantation after open heart surgery were included in the Tp+ group, and those who did not in the Tp- group Between June 2008 and December 2012, 127 dialysis dependent patients awaiting kidney transplant and who underwent open heart surgery were separated into two groups. Those who underwent transplantation after open heart surgery were determined as Tp+ (n=33), and those who did not as Tp- (n=94). Both groups were compared with respect to preoperative paramaters including age, sex, diabetes mellitus (DM), hypertension (HT), hyperlipidemia (HL), obesity, smoking, chronic obstructive pulmonary disease (COPD), peripheral vascular disease (PVD), left ventricle ejection fraction (EF), Euroscore; operative parameters including cross clamp time, perfusion time, number of grafts, use of internal mammary artery (IMA); postoperative parameters including revision, blood transfusion, ventilation time, use of inotropic agents, length of stay in the intensive care unit and hospital, and follow up findings. Problems encountered during follow up were recorded. Predictors of mortality were determined and the survival was calculated. Among the preoperative parameters, when compared with the Tp- group, the Tp+ group had significantly lower values in mean age, presence of DM, obesity, PVD, and Euroscore levels, and higher EF values. Assessment of postoperative values showed that blood transfusion requirement and length of hospital stay were significantly lower in the Tp+ group compared to the Tp- group, whereas the length of follow up was significantly higher in the Tp+ group. The use of inotropic agents was significantly higher in the Tp- group. A logistic regression analysis was made to determine the factors affecting mortality. Revision (p=0.013), blood transfusion (p=0.017), ventilation time (p=0.019), and length of stay in the intensive care unit (p=0.009) were found as predictors of mortality. Survival rates at years 1, 2 and 3 were 86.1%, 81%, 77.5% in the Tp- group, and 96.0%, 96.3%, 90.4% in the Tp+ group. Median survival rate was 41.35±2.02 in the Tp- group, and 49.64±1.59 in the Tp+ group which was significantly higher compared to the Tp- group (p=0.048). Chronic renal failure is among the perioperative risk factors for patients undergoing open heart surgery. Transplantation is still an important health issue due to insufficiency of available transplant organs. Patients with chronic renal failure are well known to have higher risks for coronary artery disease. A radical solution of the cardiovascular system problems prior to kidney transplantation seems to have a significant contribution to the post transplant survival.

Apical hypertrophic cardiomyopathy--case report and review of the literature.

Hypertrophic cardiomyopathy is a well-known clinical entity. Hypertrophy engraving the left ventricular apex, so called, apical hypertrophic cardiomyopathy (characterized by the giant negative T waves at ECG and a "spade-like" view of left ventricle) is very rare variant of the pathology. In this report, we present a 51-year-old patient with apical hypertrophic cardiomyopathy together with a brief review of the literature. It was concluded that in patients presenting to the clinic with typical or atypical chest pain or dyspnea, in whom ECG indicating negative giant T waves, before an early invasive strategy, the diagnosis of ApHCM should be kept in mind and an echocardiography should be performed to confirm the diagnosis. Additionally; not only the ApHCM can easily mimic the life threatening condition of acute coronary syndrome but also these two may be seen simultaneously but independently in the same patient. For this reason before making the final diagnosis the physicians always exclude the conditions, which may lead to acute coronary syndromes.

Vacuum assisted closure improves the quality of life in patients with diabetic foot.

BACKGROUND: Diabetes Mellitus (DM) is the most common endocrine disease worldwide. One of the most important chronic complications of this disease is the development of diabetic foot. The management of diabetic foot wounds is quite important with respect to public health. AIMS: To determine the effect of Vacuum Assisted Closure (VAC) therapy on the quality of life in the treatment of diabetic foot ulcers and compare it with standart wound care. METHODS: Between May 2007 to December 2008, 67 consecutive patients with diabetic foot ulcers were randomly assigned to VAC therapy (Group 1, n : 30) or standart wound care (Group 2, n : 37). The SF-36 questionnaire was administered the day before and in the month following wound healing. Global analyses of the 8 domains and 2 comprehensive indexes of SF-36, Physical Component Summary (PCS) and Mental Component Summary (MCS) were performed. Clinical measures included standard antidiabetic treatment, daily wound care including antiseptic bath, debridement, toe removal for gangrene when necessary, and wound care with conventional methods or VAC. Healing time was calculated as the time from hospital admission to the time of re-epithelization. RESULTS: There were no differences in the mean age, ulcer size and pulse status of the patients in both groups. Healing time in the VAC group was significantly reduced (p < 0.05). All 8 domains of SF-36 and MCS and PCS scores improved remarkably after VAC therapy. CONCLUSION: Vacuum Assisted Closure therapy was found to be effective in the treatment of chronic diabetic ulcers. The improvement of quality of life demonstrates a clear-cut indication in this particular group of patients.

Predictive value of intraoperative in situ radial artery conduit flow assessment prior to harvesting during coronary artery bypass surgery.

OBJECTIVE: Radial artery (RA) is increasingly preferred as the second best conduit in coronary artery bypass grafting (CABG). Harvesting techniques affect the integrity of the RA with implications for the immediate and late outcome. The aim of this study was to describe a simple intra-operative technique that allows the quality of the RA to be assessed prior to its harvesting during CABG. METHODS: The study group consisted of 54 patients who underwent CABG. A 2-cm vertical incision was made over the nondominant RA pulse. A limited pedicle of the RA was positioned inside the metal cradle of the flexible flow probe. Baseline transit-time ultrasonic flow and pulsatility index (PI) were measured. RESULTS: Average IN SITU RA flow was 18.6 ml/min (range 4-51 ml/min). Of 14 IN SITU RAs, all but three RAs were found to have adequate flow characteristics and were used as conduits. In the three unsuitable RAs, one had complete obliteration and no flow; one had visible calcifications and very low flow and the third one had a weak pulse, low flow and high PI. CONCLUSION: Routine assessment of IN SITU RA flow characteristics via a 2-cm incision provides useful information about RA conduit quality prior to its formal harvesting during CABG. Despite considerable skepticism about the use of the radial artery due to its vasospastic potential, this technique may increase utilization rates of the RA as a conduit during CABG, in particular in many young diabetic patients.

Pituitary apoplexy following coronary artery bypass grafting: report of a case.

Abstract. Pituitary apoplexy can rarely occur after surgical procedures, mainly due to severe haemorrhage or hypotension. It is a serious condition that may lead to devastating complications and even to death. We present a 60-year-old male patient in whom pituitary apoplexy developed due to protamine anaphylaxis during coronary artery bypass surgery.

Curcumin nutrition for the prevention of mesenteric ischemia-reperfusion injury: an experimental rodent model.

BACKGROUND: Curcumin is an anti-oxidant molecule known to be a potent inhibitor of nuclear factor-kappaB (NF-kappaB). It has been shown to attenuate ischemia/reperfusion (I/R) injury in several organ systems. In this study, we sought to investigate the effects of curcumin on the prevention of superior mesenteric artery I/R injury in rats. METHODS: Wistar albino rats were randomly allocated to 3 groups: group I, sham operated (n = 10); group II, I/R injury only (n = 10); group III, curcumin-treated I/R cohort (n = 10). Group I animals underwent laparotomy without I/R injury. After group II animals underwent laparotomy, 60 minutes of superior mesenteric artery ligation were followed by 3 hours of reperfusion. In the curcumin group, 15 days before I/R, curcumin (40 mg/kg) was administered by gastric gavage. All animals were sacrificed at the end of reperfusion. Intestinal tissue samples were obtained to investigate intestinal mucosal injury; in addition we estimated levels of myeloperoxidase (MPO) activity, malondialdehyde (MDA), nitric oxide (NO), glutathione (GSH), interleukin (IL)-6, and tumor necrosis factor (TNF)-alpha. RESULTS: There were statistically significant decreases in GSH levels, along with an increase in intestinal mucosal injury scores, MPO activity, MDA levels, NO, IL-6, and TNF-alpha in group I when compared with groups II and III (P = .01). Curcumin treatment in group III produced a significant increase in GSH levels, as well as a decrease in intestinal mucosal injury scores, MPO activity, MDA, and NO levels when compared with group II (P < .05). CONCLUSION: This study showed that curcumin treatment significantly attenuated reperfusion injury in a superior mesenteric artery I/R model in rats.

Iatrogenic bronchopleural fistula occuring during redo cardiac surgery.

Cardiac re-operations are associated with increased morbidity and mortality rates due to adhesion of tissues in the anterior mediastinum. Especially, previous usage of left internal thoracic artery constitutes a major challenge for cardiovascular surgeons. In such cases, the left lung frequently adheres to the thoracic wall and may be injured during dissection. This leads to air leak and the complication may in turn increase the risk of mediastinal infections and the hospital stay. A bronchopleural fistula case treated by a novel technique is reported. In patient iatrogenic bronchopleural fistula occured during dissection of the adhesions which resulted due to the first coronary artery bypass grafting and left internal thoracic artery usage. The air leakage was successfully controlled and treated by a novel method: self adhesive BioGlue immersed and coated Surgicel patch. Although it is a single case experience it may be a promising method as it is less traumatic when compared to the classical treatment methods of bronchopleural fistula.

Cell sources for cardiovascular tissue regeneration and engineering.

The heart has long been regarded as a post-mitotic organ. Since many years, physicians have focused on developing strategies to restore the myocardium after ischemic damage followed by ventricular dysfunction. Restoration is generally achieved through the redirection of blood flow or by supporting contractile performance. The discovery of stem cells capable of generating angiogenic or contractile cells and structures offers new horizons to patients suffering from myocardial disease. Experimental studies indicate that the delivery or mobilization of stem and progenitor cells may improve tissue perfusion and the contractile performance of the damaged heart. Another aspect of restoration is based on cardiovascular tissue engineering and the creation of three-dimensional biological conformations to replace the artificial materials frequently used during operations, i.e., valves and grafts, or even a portion of the nonfunctional myocardial tissue. At present, the underlying intra- and intercellular molecular mechanisms controlling myocardiogenesis and cardiomyocyte replacement during regenerative processes are not very well understood. In this brief review we try to give the answers to questions on certain aspects of myocardial tissue regeneration and engineering procedures.

Modified central aortopulmonary shunt with end-to-end anastomosis of the shunt to the pulmonary trunk: Early results of a novel shunt procedure for first-stage palliation of infants with pulmonary atresia and hypoplastic pulmonary arteries.

OBJECTIVE: The aim was to investigate a novel palliative shunt performed between the ascending aorta and the main pulmonary artery in patients with pulmonary atresia. PATIENTS AND METHODS: Thirteen patients with intracardiac defects [tetralogy of Fallot (seven patients); tetralogy of Fallot and major aortopulmonary collateral arteries (one patient); ventricular septal defect and major aortopulmonary collateral arteries (two patients); tricuspid atresia (three patients)] and pulmonary atresia underwent shunt operation. Patient selection was made based on preoperative echocardiography and perioperative findings. Eight of the patients were female and five were male. Ages and weight ranged between 1-235 days and 2,950-7,900 g, respectively. Preoperative room air oxygen saturation ranged between 68-83 %. RESULTS: Operations were performed through a median sternotomy. The main pulmonary artery was transected from the right ventricular outflow tract and using a 3-3.5 mm diameter graft, a modified central aortopulmonary shunt was created (graft anastomosis was end-to-end to the pulmonary artery and side-to-side to the aorta). Postoperative oxygen saturation increased 5-10% and diastolic blood pressure decreased by 3-6 mmHg. One hospital mortality occurred, due to sepsis, and two late deaths, one due to pneumonia and one sudden death, occurred in the follow-up period. Patients were followed up for 3-16 months after the operations. During the follow-up period four patients received corrective operations, one unifocalization and three total corrections. CONCLUSION: Modified central aortopulmonary shunt with end-to-end anastomosis of the shunt to the pulmonary trunk is a novel palliative shunt operation. Our early results with this technique indicate rapid palliation and early achievement of bilateral homogenous adequate pulmonary artery size with a low incidence of overflow to pulmonary circulation and minimal arterial distortion.

Comparison of transperitoneal and retroperitoneal approaches in abdominal aortic surgery.

BACKGROUND: The transperitoneal approach (TP) to the aorta is the most widely accepted surgical approach in aortic surgery as it is simple, fast and provides excellent exposure of the intra-abdominal cavity and vascular structures. In recent years, there has been an increasing interest in the retroperitoneal (RP) approach to the aorta since it has been described as having a better outcome, i.e., preserving pulmonary function and gastro-intestinal physiology, reducing the intra-operative blood loss, minimising patient discomfort or pain, decreasing the incidence of wound complications and shortening ICU and hospital stay. The aim of this study is to compare the transperitoneal and retroperitoneal approaches in aortic surgery for aorto-iliac occlusive disease (AIOD). METHODS: From December 2003 to June 2006, a total of 153 consecutive patients who had undergone aortic surgery for AIOD, were studied retrospectively. The TP approach was used in 85 patients and the RP approach in 68 patients. Demographic features, intra-operative and postoperative data were analysed and compared according to the approach used. RESULTS: The mean operating time (83.6 +/- 23 vs. 104.4 +/- 30 min, p < 0.001) and mean aortic cross-clamp time (18.4 +/- 3 vs. 15.2 +/- 3 min, p < 0.0412) were significantly longer in the RP group. Peri-operative blood loss (700 +/- 350 vs. 650 +/- 330 ml, p < 0.683) and mortality rate < or = 30 day (1/1.2% vs. 0/0.0%, p < 0.896) were similar between the groups. The operative 30 day mortality rate was 0.7% (1 of 153) overall. The RP group had an earlier return of bowel functions (17.1 < or = 3 vs. 24.2 < or = 5 hrs, p < 0.001), earlier resumption of diet (26.4 < or = 4 vs. 31.4 < or = 5 hrs, p < 0.001), shorter period of intubation (3.5 < or = 2 vs. 6.5 < or = 3 hrs, p < 0.001), ICU stay (1.5 < or = 1 vs. 4.2 < or = 1 hrs, p < 0.001) and hospital stay (4.0 < or = 1 vs. 5.9 < or = 1 days, p < 0.001). Mean effort-pain scores were significantly lower in the RP group (3.8 < or = 1 vs. 5.3 < or = 1, p < 0.001). Incidence of pulmonary complications (4.4%, 3 of 68 vs. 7.3%, 8 of 85, p < 0.001), paralytic ileus (1.5%, 1 of 68 vs. 3.5%. 3 of 85, p < 0.001) were also lower in the RP group. Wound complications were more common in the TP group (4.7%, 4 of 85 vs. 10.3%, 7 of 86, p < 0.001). Most cases in both groups were related to incisional hernia or evisceration. CONCLUSION: This report presents our experience with the use of TP and RP approaches in a patient population merely consisting of AIOD. The RP approach was associated with a significantly lower incidence of postoperative pulmonary complications, rapid recovery of gastro-intestinal functions, shorter ICU and hospital stay, less peri-operative blood loss and lower mean effort-pain scores. We conclude that the RP approach is a safe and feasible technique that exposes patients to less postoperative complications.

Standard open repair versus minilaparotomy approach for abdominal aortic aneurysms: what is the best approach in patients with ischemic heart disease?

AIM: The beneficial effects of minilaparotomy approach in patients undergoing abdominal aortic aneurysm (AAA) repair have been defined. In this respect, the authors compared treatment outcome and procedure-related mortality rates of minilaparotomy technique with those of open standard repair in patients with ischemic heart disease. METHODS: The authors retrospectively reviewed data on 212 patients who underwent elective AAA repair via a minilaparotomy approach at the Hospital of Istanbul over an 8-year period from February 1995 to January 2003. The clinical study included 46 patients who have only ischemic heart disease as a sole risk factor. This group was matched in a case-control fashion to a group of 57 patients with similar characteristics who were operated via standard median laparotomy. All available clinical, pathologic and postoperative data were reviewed and analyzed for postoperative outcome. RESULTS: Mean operative times in mini- and standard laparotomy groups were 190+/-26 min and 165+/-15 min, respectively (P=0.32). Aortic clamping times did not differ significantly between two groups (61+/-12 min vs 53+/-10 min, P=0.43). Blood requirement was lower in minilaparotomy group. Five patients (8.7%) in the standard median laparatomy group died, while one death (2%) occurred in the other group (P<0.01). In patients who have undergone traditional repair, 5 patients suffered from myocardial infarction and 4 patients required prolonged mechanical ventilation. No coronary ischemic event was noticed in minilaparotomy patients. The minilaparotomy group had significantly shorter lengths of hospital (6.2+/-1.1 vs 9.3+/-2.8 days, P=0.03) and intensive care unit (ICU) stays (7.8+/-2.3 vs 14.5+/-3.2 hours, P=0.01). Duration of adynamic ileus (1.9+/-0.6 vs 2.8+/-1.1 days, P=0.02), return to normal diet (3.2+/-1.0 vs 4.6+/-1.3 days, P=0.01) and day of ambulation (1.5+/-0.3 vs 3.2+/-0.7 days, P=0.001) were significantly lower in the minilaparotomy group. The standard median laparotomy group was twice as costly as the minilaparotomy group (3 200+/-600 vs 5 900+/-900 US dollars, P=0.001). CONCLUSION: The minilaparotomy technique has advantages that include less postoperative morbidity and mortality rates, early resumption of intestinal functions, reduced cost, decreased length of stay in the ICU and hospital. There-fore, the authors believe that this approach is still a valid alternative approach in the treatment of patients with AAA having ischemic heart disease as a risk factor.

Intracardiac erythropoietin injection reveals antiinflammatory potential and improved cardiac functions detected by Forced Swim Test.

Systemic administration of erythropoietin (Epo) protects the myocardium from an ischemic insult and promotes beneficial remodeling. We hypothesized that intracardiac injection of Epo may exhibit cardioprotective potential with reduced systemic toxicity. Following myocardial infarction (MI), Epo was injected directly into the border of the infarction. Six weeks after an MI, we evaluated infarction size, angiogenesis, and pathologic effects of the treatment. Myocardial performance was assessed with a Forced Swim Test adapted to the study. Anti-inflammatory and cellular proliferative effects of Epo were analyzed by measuring expression of integrin-beta and CdK4 by reverse transcriptase-polymerase chain reaction (RT-PCR). The findings indicated improved cardiac status with direct Epo administration. Exercise capacity detected by the Forced Swim Test was significantly increased. There was radical reduction of absolute infarction size, ventricular dilatation, and hypertrophy in the Epo group. Integrin-beta was down-regulated and CdK4 expression was increased significantly with Epo. In conclusion, the study demonstrated that intramyocardial Epo injection, following MI, reduced inflammation, enhanced angiogenesis and proliferation, improved myocardial functions, and did not lead to intramural thrombus formation.

Interrupted aortic arch in adulthood.

Interrupted aortic arch is one of the rarest anomalies among the congenital cardiac defects. Patients must be treated early in life, otherwise death is inevitable. Reports on adult patients with aortic interruption are very rare in the literature. In this report, we present a 21-year-old patient with type A interrupted aortic arch. The patient underwent successful anatomical reconstruction of the descending aorta.

Cyanoacrylate gluing increases the effectiveness of systemic antimicrobial treatment in sternal infection: experimental study in a rodent model.

BACKGROUND: Sternal infection is a serious complication of cardiac surgery requiring resternotomy and radical debridement. In this experimental study, we aimed to test our hypothesis that the use of cyanoacrylate gluing (application of an acrylic resin, a monomer of cyanoacrylate molecules, which rapidly polymerizes in the presence of water, forming long, strong chains and joining the bonded surfaces together) together with systemic antimicrobial therapy will provide synergy for the treatment of sternal infection caused by methicillin-resistant Staphylococcus aureus (MRSA). METHODS: Forty Wistar albino rats were randomly divided into four groups: Group I, uncontaminated sham group; Group II, untreated contaminated control group; Group III, contaminated group receiving only systemic vancomycin therapy; Group IV, contaminated group treated with a combination of cyanoacrylate gluing and systemic vancomycin. Cyanoacrylate gluing was applied on the 3rd postoperative day and all rats alive at the end of 8th week were sacrificed. The degree of sternal infection was assessed histologically and also by quantitative culture analysis. RESULTS: Histological evaluation revealed that cyanoacrylate was degraded and replaced by connective tissue at the end of the 8th week. Culture analysis revealed that the average growth of microorganisms was significantly reduced in Groups III and IV. In Group IV, the reduction in the amount of growing microorganisms was found to be more pronounced and significantly lower than in Groups II and III. CONCLUSION: Our experimental model suggests that cyanoacrylate gluing provides significant synergy for systemic antimicrobial therapy. However, further clinical trials are required in order to use this treatment modality safely in patients, even though our study demonstrated successful results in the treatment of mediastinitis and sternal osteomyelitis in rats.

Treatment of chronic type B aortic dissection by endovascular grafting in a previously CABG patient. Case report.

High mortality rates resulting from the surgical treatment of Type B aortic dissections have played an important role in seeking newer alternative therapy modalities for the treatment of the pathology. Especially since the early 1990s, endovascular grafting has become a popular option in the treatment of aortic diseases and with the increasing experience and advances in technology, it has, in recent years, become an alternative approach for the treatment of aortic dissections. In this report, we present the treatment of a 56-year-old male patient with a history of a coronary artery bypass grafting who presented with chronic type B aortic dissection. Endovascular stent graft implantation was performed with a hybrid therapy type of preliminary right subclavian artery to left subclavian artery bypass, followed by endovascular stent graft implantation to the dilated aneurismal segment of the descending aorta, for the treatment of chronic type B aortic dissection. The procedure and the postoperative course were uneventful; moreover, they were very comfortable for the patient undergoing an investigation of the descending aorta, when compared with the conventional surgical treatment modalities.

Epidural anaesthesia and mini-laparotomy for the treatment of abdominal aortic aneurysms in patients with severe chronic obstructive pulmonary disease.

PURPOSE: The purpose of this study is to compare the use of epidural and general anaesthesia techniques in the treatment of abdominal aortic aneurysms (AAA) through mini-laparotomy in patients with severe chronic obstructive pulmonary disease (COPD). METHODS: Between March 2002 and October 2005, 23 patients with severe COPD underwent elective infrarenal abdominal aortic aneurysm repair. Endovascular therapy could not be established due to financial reasons and health insurance policies. All the operations were performed through mini-laparotomy, using epidural anaesthesia on 10 patients (Group I) and general anaesthesia on the remaining patients (Group II). Pulmonary disease was diagnosed by clinical history and pulmonary function tests. The diagnosis of severe COPD was made with the presence of one or more of the following criteria : Room air PaO2 < or = 60 mmHg, PaCO2 > or = mmHg in arterial blood gas samples, FEV1 < or = 50% of predicted value and FVC < or = 75% of predicted value in respiratory function tests. RESULTS: There was no significant difference between the ages, sex, pre-operative morbidity status, operation time and total blood loss of the patients in the two groups. Postoperative intensive care unit requirement, postoperative pulmonary complications and hospital stay were significantly higher in group II. All patients tolerated surgery safely. There was one in-hospital mortality from group II on the 35th postoperative day due to prolonged entubation and sepsis related to pulmonary infections. There was no late morbidity or mortality related to the technique in the postoperative follow-up period of the discharged patients. CONCLUSION: Epidural anaesthesia for abdominal aortic aneurysm repair through mini-laparotomy is feasible and should be especially considered in patients with severe COPD where endovascular treatment could not be performed.

Aortic arch replacement without circulatory arrest: a simplified technique with two grafts.

Aortic arch reconstruction remains a challenge for the cardiothoracic surgeon. We present our simplified technique in which we used two grafts for arch reconstruction without circulatory arrest. It is a relatively easy and quick technique consisting of a unique modification of the selective antegrade cerebral circulation system without the need for circulatory arrest in selected cases.

Surgery of the carotid artery: local anaesthesia versus general anaesthesia.

OBJECTIVE: Carotid artery surgery is safely and commonly performed under general, regional or local anaesthesia. The aim of the study was to compare local and general anaesthesia in carotid artery surgery in order to establish whether differences exist in terms of peri-operative results, use of intra-operative shunts and costs. METHODS: We retrospectively reviewed the data on 426 patients who underwent carotid endarterectomy with either local or general anaesthesia at our institution over a four-year period. All available clinical, pathologic and postoperative data were reviewed and analyzed for postoperative results. Surgical indications, outcome, operative techniques, and complications were compared. RESULTS: A total of 306 carotid endarterectomy operations under local, and 127 under general anaesthesia were performed and analyzed. Groups were similar in terms of age, sex and pre-operative risk factor distribution. The local anaesthesia group was associated with a lower incidence of shunt placement and operative time when compared to the general anaesthesia group. Postoperative intensive care unit requirement, hospital stay and costs were also lower with local anaesthesia. Significant difference in neurological complications and mortality rate was not observed between the two groups. CONCLUSION: Carotid endarterectomy performed under local or general anaesthesia is associated with low morbidity and mortality rates. Local anaesthesia enables the surgeon to assess the neurological status during the procedure. It is also associated with decreased shunt usage, decreased operative time and, in high risk patients, lower intensive care unit requirement and hospital stay.