Current surgical approaches in Takayasu's arteritis: a single-centre experience.

OBJECTIVES: We investigated cardiovascular surgical interventions in a group of patients with Takayasu's arteritis (TAK) diagnosed and followed by a single centre. METHODS: . Twenty patients with TAK (5 males, 15 females, mean current age: 38.1±10.7) who were operated for a broad spectrum of cardiovascular diseases ranging from coronary heart disease to coeliac stenosis or aneurysm between July 2008 and April 2016 were studied. One patient underwent operation related to aneurysm of ascending aorta and aortic insufficiency, 2 patients had operations for both coronary arteries originating from aortic arch, 6 patients for only arteries originating from aortic arch, 1 patient for both carotid and infra-inguinal artery, 5 patients for aorta-iliac or femoral revascularisation, 5 patients for renal artery and/or coeliac or superior mesenteric artery revascularisations. Three of these interventions were endarterectomy and patch plasty. RESULTS: The mean time between diagnosis and surgical intervention was 6.1±3.1 years (range: 3 months-12 years). A total of 4/32 (12.5%) grafts were occluded during the follow up period of mean 39.2±24.6 months. Secondary interventions like cross-femoral, or graft to superficial femoral artery bypasses were needed in 2 patients who underwent aorta-bifemoral bypasses to keep patency. There was no operative mortality. We did not observe any anastomotic aneurysm. One patient died due to graft infection 3 months after the operation. Stroke occurred in 2 patients who underwent re-vascularisations of the arteries originating from aortic arch. CONCLUSIONS: In our series, we have a relatively good midterm patency rates in patients with TAK and did not observe any anastomotic pseudoaneurysm. Stroke developed in 2 patients and mortality occurred in one patient due to the graft infection 3 months after the operation. In patients with limited carotid or aorta-iliac stenosis, chance for endarterectomy should be evaluated. Well-controlled disease activity with intensive medical treatment and multi-disciplinary approach could be associated with a favourable long-term outcome.

Upregulation of OLR1 and IL17A genes and their association with blood glucose and lipid levels in femoropopliteal artery disease.

Oxidized low-density lipoprotein receptor 1 (OLR1) and interleukin 17A (IL17A) have pro-inflammatory roles in the development of cardiovascular disorders. The present study evaluated the association of OLR1 and IL17A and their polymorphisms with the development of femoropopliteal (FP) artery disease. The mRNA expression of OLR1 and IL17A in peripheral blood mononuclear cells as well as the frequency of OLR1 rs11053646 and IL17A rs8193037 and rs3819025 polymorphisms were assessed by polymerase chain reaction in 70 patients with FP artery disease and 80 age-matched disease-free controls. Furthermore, the levels of plasma cytokines were assessed by multiplex immunoassay. OLR1 and IL17A mRNA expression was significantly higher in patients with FP artery disease compared with that in controls (P<0.001). No significant difference was observed in the genotypic frequencies of OLR1 rs11053646 (P=0.87) or in IL17A rs8193037 and rs3819025 (P=0.80 and 0.92, respectively) polymorphisms between patients with FP artery disease and controls. Plasma IL4, -6, -10, -22, -31 and -33 as well as soluble cluster of differentiation 40 ligand and tumor necrosis factor-α levels were significantly increased among FP artery disease patients compared with controls (P<0.05). Furthermore, OLR1 expression was positively correlated with triglyceride (r=0.463, P<0.001), low-density lipoprotein cholesterol (r=0.507, P<0.001) and total cholesterol levels (r=0.357, P=0.006) in patients with FP artery disease. To the best of our knowledge, the present study was the first to identify an association between OLR1 and IL17A genes and FP artery disease. OLR1 and IL17A mRNA transcripts may be associated with blood lipid parameters and with the development of FP artery disease.

Corkscrew Collateral Vessels in Buerger Disease: Vasa Vasorum or Vasa Nervorum.

PURPOSE: To investigate the origin of "corkscrew" collateral vessels around the occluded popliteal artery in patients with Buerger disease by Doppler ultrasound (US) and magnetic resonance (MR) imaging in tandem with digital subtraction angiography (DSA). MATERIALS AND METHODS: Between January 2013 and June 2015, 42 patients diagnosed with Buerger disease were identified retrospectively. Patients in whom occlusion of the popliteal artery was found on DSA of the lower extremity were subjected to Doppler US and MR imaging prospectively. Fifteen of 42 patients were identified as having the required characteristics, of whom 10 participated in the present study. RESULTS: Ten patients with occlusion of the popliteal artery were selected for inclusion, and 12 lower limbs of these patients were investigated. The study cohort comprised one woman and nine men with a mean age of 41 years ± 10 (standard deviation; range, 39-58 y). Corkscrew collateral vessels identified on DSA examinations were also identified on secondary imaging (Doppler US and MR imaging) in all patients except one in whom the popliteal artery was reconstituted after short-segment occlusion. The origin of the corkscrew collateral vessels was identified as the vasa nervorum of the tibial nerve in nine patients. CONCLUSIONS: Data from the present study suggest that corkscrew collateral vessels at the knee level in patients with Buerger disease originate from the vasa nervorum of the tibial nerve rather than the vasa vasorum of the popliteal artery if the latter is occluded.

Increased IL18 mRNA levels in peripheral artery disease and its association with triglyceride and LDL cholesterol levels: a pilot study.

Peripheral artery disease (PAD) typically refers to lower limb vessel ischemia caused by atherosclerotic stenosis of lower extremity arteries. IL18 is a pleiotropic pro-inflammatory cytokine reported to function as an inflammatory biomarker in cardiovascular diseases. IL18 activity is balanced by high-affinity naturally occurring IL18-binding protein (IL18BP). This study aimed to determine whether IL18, IL18 BP mRNA levels and -137 G/C (rs187238) polymorphism, which was previously associated with IL18 gene transcriptional activity, were associated with PAD etiology. IL18, IL18BP mRNA levels from peripheral blood mononuclear cells and -137 G/C (rs187238) polymorphism were determined by quantitative real-time polymerase chain reaction (qRT-PCR) and RT-PCR, respectively, in 55 PAD patients (26 aorta-iliac, 29 femoro-popliteal) and 61 disease-free controls. IL18 mRNA levels were increased in PAD patients compared with healthy controls (p = 0.09); however, did not reach a statistical significant level, also did not significantly differ between aorta-iliac and femoro-popliteal occlusive PAD subgroups (p = 0.285). However, IL18BP mRNA levels were significantly lower in PAD group compared with controls (p < 0.001). Genotype frequencies of rs187238 polymorphism did not significantly differ between PAD patients and controls (p = 0.385). IL18 mRNA levels were significantly correlated with triglycerides and LDL cholesterol levels in PAD patients (p = 0.003, p = 0.014, respectively). HDL cholesterol levels were negatively correlated with IL18 mRNA levels in controls (p = 0.05). This report is a preliminary study to show an association between IL18, IL18BP mRNA levels and PAD and suggests that the IL18 gene may have a significant relationship with triglyceride and LDL cholesterol levels in PAD patients.

The management and the diagnosis of fever of unknown origin.

Prolonged fever presents a challenge for the patient and the physician. Fever with a temperature higher than 38.3°C on several occasions that lasts for at least 3 weeks and lacks a clear diagnosis after 1 week of study in the hospital is called a fever of unknown origin (FUO). More than 200 diseases can cause FUO, and the information gathered from history taking, physical examination, laboratory and imaging studies should be evaluated with care. History taking and physical examination may provide some localizing signs and symptoms pointing toward a diagnosis. Infection, cancers, noninfectious inflammatory diseases and some miscellaneous diseases are the main etiologies, and some patients remain undiagnosed despite investigations. Tuberculosis, lymphoma and adult-onset Still's disease are the main diseases. Fluorodeoxyglucose PET is a promising imaging modality in FUO. Establishing a uniform algorithm for FUO management is difficult. Every patient should be carefully evaluated individually considering the previous FUO management experience.

Calcium dobesilate may improve hemorheology in patients undergoing coronary artery bypass grafting.

BACKGROUND: Calcium dobesilate is an angioprotective agent that has positive effects on hemorheological parameters. It is an antioxidant that increases endothelial-derived vasodilator substance secretion, there are none that analyze its effects during the postoperative period of patients undergoing myocardial revascularization. OBJECTIVE: We aimed to determine the effects of calcium dobesilate on hemorheological parameters, such as reduced glutathione and malondialdehyde in patients with ischemic heart disease undergoing myocardial revascularization in the postoperative period. METHODS: One hundred and thirty-four patients operated for coronary heart disease were included in this study. Hemorheological, oxidant and antioxidant parameters were measured two days after surgery and after a period of treatment with calcium dobesilate. Then, 500 mg of calcium dobesilate was given twice a day to one group of 68 patients for three months. The control group was composed of 66 patients who did not receive this medication. RESULTS: The increase in the erythrocyte deformability index was found to be significant compared with both the pretreatment values and with the 1st and 2nd values of the control group after calcium dobesilate administration, whereas there were no significant changes in blood viscosity, glutathione (GSH) or malondialdehyde (MDA) values after the calcium dobesilate administration. The same improvement in the CCS class was observed in patients regardless of they received the calcium dobesilate treatment. CONCLUSION: In the present investigation, the same improvement in the CCS class was observed in patients regardless of they received the calcium dobesilate treatment. Improvements with calcium dobesilate were statistically significant only in the increase in erythrocyte flexibility.

Calcium dobesilate may improve hemorheology in patients undergoing coronary artery bypass grafting / Dobesilato de cálcio pode melhorar hemorreologia em pacientes submetidos à cirurgia de revascularização miocárdica

BACKGROUND: Calcium dobesilate is an angioprotective agent that has positive effects on hemorheological parameters. It is an antioxidant that increases endothelial-derived vasodilator substance secretion, there are none that analyze its effects during the postoperative period of patients undergoing myocardial revascularization. OBJECTIVE: We aimed to determine the effects of calcium dobesilate on hemorheological parameters, such as reduced glutathione and malondialdehyde in patients with ischemic heart disease undergoing myocardial revascularization in the postoperative period. METHODS: One hundred and thirty-four patients operated for coronary heart disease were included in this study. Hemorheological, oxidant and antioxidant parameters were measured two days after surgery and after a period of treatment with calcium dobesilate. Then, 500 mg of calcium dobesilate was given twice a day to one group of 68 patients for three months. The control group was composed of 66 patients who did not receive this medication. RESULTS: The increase in the erythrocyte deformability index was found to be significant compared with both the pretreatment values and with the 1st and 2nd values of the control group after calcium dobesilate administration, whereas there were no significant changes in blood viscosity, glutathione (GSH) or malondialdehyde (MDA) values after the calcium dobesilate administration. The same improvement in the CCS class was observed in patients regardless of they received the calcium dobesilate treatment. CONCLUSION: In the present investigation, the same improvement in the CCS class was observed in patients regardless of they received the calcium dobesilate treatment. Improvements with calcium dobesilate were statistically significant only in the increase in erythrocyte flexibility.

ANTECEDENTES: O dobesilato de cálcio é um agente angioprotetor que tem efeitos positivos sobre os parâmetros hemorreológicos. É um antioxidante que aumenta a secreção endotelial derivada da substância vasodilatadora, não há nada que analisar os seus efeitos durante o período pósoperatório de pacientes submetidos a revascularização do miocárdio. OBJETIVO: Nosso objetivo foi determinar os efeitos de dobesilato de cálcio sobre os parâmetros hemorreológicos, tais como glutationa reduzida e malondialdeído em pacientes com doença cardíaca isquêmica submetidos a revascularização do miocárdio no pós-operatório. MÉTODOS: Cento e trinta e quatro pacientes operados por doença cardíaca coronária foram incluídos neste estudo. Parâmetros de oxidante, hemorreológicos e de antioxidantes foram medidos dois dias após a cirurgia e após um período de tratamento com o dobesilato de cálcio. Em seguida, 500 mg de dobesilato de cálcio foi administrado duas vezes por dia para um grupo de 68 pacientes durante três meses. O grupo controle foi composto por 66 pacientes que não receberam essa medicação. RESULTADOS: O aumento do índice de deformabilidade dos eritrócitos foi considerado significativo comparado com ambos os valores pré-tratamento e com os 1º e 2º valores do grupo controle após a administração dobesilato de cálcio, enquanto que não houve alterações significativas na viscosidade do sangue, na glutationa (GSH) ou malondialdeído (MDA) após a administração dobesilato de cálcio. A mesma melhoria na classe CCS foi observada em pacientes independentemente de terem recebido tratamento com dobesilato de cálcio. CONCLUSÃO: Na presente investigação, a mesma melhora na classe CCS foi observada em pacientes independentemente de terem recebido o tratamento com dobesilato de cálcio.

Efficacy of tigecycline and vancomycin in experimental catheter-related Staphylococcus epidermidis infection: microbiological and electron microscopic analysis of biofilm.

Central venous catheters are frequently used. The commonest cause of catheter-related bloodstream infections (CRBSI) is coagulase-negative staphylococci (CoNS) associated with adherent biofilm. Tigecycline, a derivative of tetracycline, acts against strains producing biofilm. In this study, we aimed to determine the effect of tigecycline in a CRBSI model. A single dose of 10(8) colony-forming units (CFU)/mL of slime-producing Staphylococcus epidermidis was given through polyethylene catheters inserted into 24 rabbits. After 72 h, groups of eight rabbits were treated with heparin, vancomycin/heparin or tigecycline/heparin. Blood obtained from peripheral veins and the catheter lumen as well as catheter tips were cultured, and three catheters from each group were studied using electron microscopy. Surfaces were randomly subdivided and areas with ≥50 bacteria were compared. Blood cultures were positive from all heparin-treated rabbits but were negative from those receiving either antibiotic (P<0.001). Catheter tip cultures revealed growth from six, two and one rabbit(s) given heparin, vancomycin and tigecycline, respectively. Electron microscopy showed that catheters from heparin-treated rabbits were most heavily colonised (more areas with ≥50 CFU) compared with catheters from animals treated with vancomycin or tigecycline (P<0.003 and P<0.001, respectively). In conclusion, this study shows that tigecycline and vancomycin are both effective for treating CRBSI due to CoNS. Electron microscopy of catheters themselves suggests that tigecycline is superior to vancomycin (P<0.001). Tigecycline may be useful for the treatment of CRBSI.

Management and prognosis of nonpulmonary large arterial disease in patients with Behçet disease.

OBJECTIVE: The purpose of this study was to evaluate and report our treatment policies in the management of nonpulmonary arterial aneurysms in Behçet disease and to assess the prognosis in a cohort of 25 patients diagnosed between 1996 and 2007 by formally reassessing their outcome at the present time. METHODS: We identified 25 patients (24 men/1 woman) with Behçet disease with nonpulmonary aneurysms (n = 23) or occlusions (n = 2) between 1996 and 2007. All patients fulfilled the International Study Group Criteria for Behçet disease. Aneurysms were demonstrated with contrast-enhanced computed tomography (CT) or magnetic resonance angiography (MRA) after first-line ultrasonography. Standard surgical procedures were carried out in 22 patients. One patient with a nonruptured saccular aortic aneurysm and 2 patients with carotid aneurysms were managed only medically. For the patients with aneurysms located in the aortic bifurcation, we preferred aorto-bi-iliac bypasses; for the six extremity aneurysms, we were able to ligate the arteries; and for the other 10 extremity aneurysms we used polytetrafluoroethylene (PTFE) grafts for bypass procedures. All patients received immunosuppression with cyclophosphamide and corticosteroids before the operation and were continued in the postoperative period. All patients were examined between January and December 2010 paying special attention for new and anastomotic aneurysms and graft patency. RESULTS: There was one death and 1 patient was lost to follow-up. The remaining 23 patients (92%) were under follow-up after a mean of 7.4 ± 2.9 years after their operation. Four PTFE grafts (40%) inserted for extremity aneurysms occluded with no disabling consequences. Also, 6 patients who were treated with ligation postoperatively began to complain of mild to moderate claudication. In 2 patients, aneurysms recurred at the anastomotic site, whereas in 3 patients, new aneurysms developed at other sites. CONCLUSION: The surgical management of large, nonpulmonary arterial disease of Behçet disease is currently quite satisfactory. When the false aneurysm is in the infrarenal aorta, aorto-bi-iliac bypass is the preferred surgical intervention. Extremity aneurysms can be treated with synthetic graft insertion. In selected cases, ligation can give satisfactory results; however, postoperative claudication is common. In some patients with small intact saccular aneurysms, surgery may not be necessary. Patients must be prescribed immunosuppressive therapy with cyclophosphamide and corticosteroids before and after the surgical intervention in order to avoid Behçet disease activation.

Anatomical variations of the carotid-vertebral arteries: "double-vessel" sign on Doppler ultrasonography.

We describe the "double-vessel" sign and its relevance for the diagnosis of carotid and vertebral arterial anatomical variations in a series of four patients with stroke. In these four patients, two arteries could be seen at the expected location of the common carotid artery (CCA), leading to the diagnosis of anatomical variations including separate origin of internal and external carotid artery from the aortic arch on the left side and from the brachiocephalic trunk and the subclavian artery on the right side, early bifurcation of the CCA on both sides, and an aberrant course of the vertebral artery on the left side. The presence of two arteries at the expected location of the CCA should raise the suspicion of carotid or vertebral arterial variations.

The in vitro effects of iloprost with other vasodilators on the human internal thoracic artery.

PURPOSE: We aimed (a) to analyze the effects of iloprost as a vasodilator on the human internal thoracic artery (ITA) and (b) to compare these effects with the effects of other vasodilators now being used in the clinic. METHODS: Following transfer into only Krebs solution or into Krebs solution containing papaverine or iloprost, human ITA strips were then incubated only in Krebs or in Krebs with vasodilators that are generally used in clinical practice, such as diltiazem or glyceryl trinitrate. Cumulative concentration-contraction curves for noradrenaline (NA) and KCl were then established for these strips. Student's t-test and one-way analysis of variance followed by Tukey-Kramer tests were used to compare differences between groups. A p <0.05 was used to indicate significance. RESULTS: Among the transfer solutions, papaverine (6.50 ± 0.20) and iloprost (7.33 ± 0.13) were significantly more potent than Krebs (8.46 ± 0.75, p <0.001 and p <0.05) with regard to preventive effect on precontracted ITA with NA. Iloprost significantly relaxed the NA-induced precontracted ITA strips in the Krebs, papaverine, and iloprost groups. Diltiazem significantly relaxed the precontracted ITA with KCl in all storage groups. CONCLUSION: Iloprost may also prevent perioperative ITA spasm, but should be tested in the clinical setting.

Nontraditional risk factors in carotid artery disease.

Carotid atherosclerosis (AS) is one of the main risk factors for ischemic stroke. Our aim is to evaluate the nontraditional biochemical markers in asymptomatic and symptomatic patients with carotid artery plaque. This study was conducted on 55 patients: 43 with symptomatic and 12 with asymptomatic carotid artery disease. Lipoprotein (a) (Lp(a)), homocysteine, adiponectin, nitric oxide (NO), and tumor necrosis factor alpha (TNF-alpha) levels were measured in the plasma. The mean of total cholesterol, triglyceride, and homocysteine levels was significantly elevated in the symptomatic group as compared with the asymptomatic group (P = .03). In the asymptomatic group, adiponectin and NO levels showed elevations as compared with the symptomatic group but this increase was not significant (P > .05). Lipoprotein (a) and TNF-alpha levels acted inversely with adiponectin and NO. There was an insignificant decline in Lp(a) and TNF-alpha levels in the asymptomatic group as compared with the symptomatic group (P > .05).

The role of oxidative stress and antioxidant defenses in Buerger disease and atherosclerotic peripheral arterial occlusive disease.

The aim of this study was to determine the status and the role of oxidative stress and antioxidant defenses in patients with Buerger disease and atherosclerotic peripheral arterial occlusive disease (PAOD). Seventy-three subjects resembling each other in general characteristics were involved in the study: 21 with lower extremity PAOD (mean age 53.05 +/- 10.8 years, 17 men and four women), 22 with Buerger disease (mean age 38.59 +/- 6.4 years, 19 men and three women), and 30 healthy volunteers (mean age 38.59 +/- 6.4 years, 22 men and eight women). We measured the levels of plasma malondialdehyde (MDA), paraoxonase (PON1), protein carbonyls, arylesterase, nitric oxide (NO), serum oxidized low-density lipoprotein (ox-LDL) and MDA, glutathione (GSH), glutathione reductase (GSH-red), glutathione peroxidase (GSH-px), superoxide dismutase (SOD), and catalase (CAT) in erythrocytes. Plasma protein carbonyls, serum ox-LDL, and plasma and erythrocyte MDA were significantly high in the Buerger disease group compared to the PAOD and control groups (p < 0.001). Plasma PON1 levels and GSH and GSH-px levels in erythrocytes in the Buerger disease group were significantly low compared to the PAOD and control groups (p < 0.001). GSH-red, SOD, and CAT levels in erythrocytes in the Buerger disease group were significantly lowcompared to the PAOD group (p < 0.01, p < 0.001, and p < 0.001, respectively). NO levels were significantly lower in the PAOD group compared to the control group (p < 0.05). The balance between oxidative stress and antioxidant capacity is more seriously impaired in Buerger disease than PAOD.

Elective shunt use for easy resection of a carotid body tumor.

Carotid body tumor resection has the potential hazards of hemorrhage, cranial nerve palsy, and cerebrovascular accident. The control of intraoperative bleeding during manipulation of the tumor is a critical issue for safe resection. In the presented case with a carotid body tumor, the Shamblin II, a carotid shunt with a dual balloon was used electively. The aim of shunt use was partial isolation of the tumor from carotid arterial circulation in a short time only. Shunt use may facilitate safe and easy resection.

Pseudocoarctation.

Pseudocoarctation, also known as kinking or buckling of the aorta, is an uncommon anomaly. Its recognition is important, because it may be mistaken for true coarctation, aneurysm or mediastinal neoplasm. A case of pseudocoarctation associated with left cervical aorta is reported. The present case is unique in the demonstration of obvious tortuosity and kink formation of the cervical aorta and main branches without frank aneurysm formation. Magnetic resonance angiography as a noninvasive imaging modality was suggested for the definitive diagnosis of cervical aortic arch and its accompanying anomalies.

Surgical treatment of Buerger's disease.

We aimed to evaluate the characteristics of 198 new patients with Buerger's disease treated surgically in the last decade. We also compared these results with our former series reported in 1993. The records of patients with Buerger's disease who were enrolled in an ongoing investigational protocol between 1991 and 2001 were reviewed. Sympathectomy was carried out in 161 patients and revascularization in 19 patients. The cumulative secondary patency rate was 57.9% for bypass grafts at a mean follow-up of 5.4 years. Clinical outcome following sympathectomy was considered improved in 52.3% of patients, stable in 27.8%, and worse in 19.8%. Seven major and 36 minor amputations were performed, with a limb salvage rate of 95.6%. The aggressiveness of the disease has increased compared with previous series, parallel to the expansion of cigarette consumption. Bypass surgery should be considered for patients with severe ischemia who have target vessels. Sympathectomy still has a role to improve distal flow.

What are the reactivities of coronary arteries harvested from the hearts exposed to cold ischemic preservation?

This study was designed to determine the effects of pretransplant ischemic hypothermic period on reactivities of major coronary arteries. Eleven pigs were used. Right, left anterior descending and circumflex coronary arteries harvested from 6 pigs following single dose of cardioplegia and cardiectomy. The same procedures were performed in 5 pigs after 6 hours static 4 degrees C hypothermic preservation of the hearts. Strips prepared from these 3 coronary arteries were placed in organ chambers and contractions with acetylcholine and histamine and KCL and dilatations with noradrenaline following submaximal contractions with acetylcholine and histamine were documented. There was no statistically significant difference between results taken from both groups. The pretransplant period (until 6 hours) does not cause important differences on the reactivities of coronary arteries.

A case of anthracosis presenting with mediastinal lymph nodes mimicking tuberculous lymphadenitis or malignancy.

Anthracosis is a form of pneumoconiosis caused by coal dust or by a smoky and polluted environment. Anthracosis often presents in pulmonary form; only rarely are extrathoracic, esophageal, and mediastinal anthracoses documented. We report a rare case of anthracosis with multiple mediastinal lymphadenopathy.