Treatment of aortic arch aneurysms: Open surgery or hybrid procedure?

BACKGROUND: This study aims to compare the results of hybrid procedure and open surgery for the treatment of aortic arch aneurysms. METHODS: Twenty-six p atients (21 m ales, 5 females; m ean a ge 56.6±12.4 years; range, 20 to 83 years) who underwent total aortic arch replacement for aortic arch aneurysm between January 2004 and January 2010 were retrospectively analyzed. The patients were divided into two groups: open conventional surgery group (group 1, n=15) and hybrid procedure (total debranching of the aortic arch and simultaneous endovascular stent) group (group 2, n=11). Survival rates and need for reoperation were compared between the groups. RESULTS: The hybrid procedure was found to be more favorable in terms of postoperative revision, extubation period, and drainage amounts. However, there was no statistically significant difference in the survival rates, need for reoperation, and major adverse cardiovascular events between the groups. CONCLUSION: Our study results suggest that conventional open surgery and hybrid procedure are similar in terms of survival and short-to-mid-term results in patients undergoing total aortic arch replacement for aortic arch aneurysm.

Surgery for false aneurysm developing after type A acute aortic dissection.

Aortic false aneurysm is life-threatening with high morbidity and mortality rates. Surgical treatment varies according to the pathologic process, infection status, and site of origin of the aneurysm. We presented a case of false aneurysm of the ascending aorta, developing after type A acute aortic dissection repair. The operation was performed with the use of deep hypothermia and circulatory arrest to avoid massive uncontrollable hemorrhage.

Early and Mid-term Outcomes in Female Patients Undergoing Isolated Conventional Coronary Surgery.

INTRODUCTION: Several observational studies comparing outcomes between female and male patients after coronary artery bypass grafting (CABG) have shown that operative mortality rate is higher among female patients than in male patients. However, some conflicting studies report that early mortality among female patients is equivalent to that among male patients. We investigated predictive factors of morbidity, mortality and survival in female patients undergoing isolated conventional CABG. METHODS: Between January 2002 and December 2009, 1657 patients underwent isolated conventional CABG in our clinic. 21.8% (n=361) of patients were female and 78.2% (n=1296) males. RESULTS: Advanced age (P<0.0001), hypertension (P<0.0001), diabetes (P<0.0001), and hyperlipidemia (P<0.0001) were the independent predictive factors among female patients. Mean in-hospital mortality rates were 5.8% and 3.2%; for females and males, respectively (P=0.029). Prolonged ventilatory support (P=0.009) and postoperative atrial fibrillation (P=0.049) were the independent predictive factors of in-hospital mortality in female patients. Cardiopulmonary bypass time (P=0.041), prolonged ventilatory support (P<0.0001), and postoperative atrial fibrillation (P=0.031) were the independent predictive factors of in-hospital mortality in male patients. Mean follow-up was 47.51±25.06 months and 48.42±25.21 months among female and male patients (P=0.820). In follow-up, mortality rate was 6.1% (n=22) among female patients and 4.6% (n=60) among male patients (P=0.272). Left internal thoracic artery (LITA) usage (P=0.001) was the independent predictive factor of survival in female patients. CONCLUSION: In-hospital mortality rate was higher in female patients. Length of ICU and hospital stay, and mid-term survival was similar between female and male patients.

Predictors of intra-aortic balloon pump insertion in coronary surgery and mid-term results.

BACKGROUND: We aimed to investigate the preoperative, operative, and postoperative factors affecting intra-aortic balloon pump (IABP) insertion in patients undergoing isolated on-pump coronary artery bypass grafting (CABG). We also investigated factors affecting morbidity, mortality, and survival in patients with IABP support. METHODS: Between January 2002 and December 2009, 1,657 patients underwent isolated CABG in Izmir Katip Celebi University Atatürk Training and Research Hospital. The number of patients requiring support with IABP was 134 (8.1%). RESULTS: In a multivariate logistic regression analysis, prolonged cardiopulmonary bypass time and prolonged operation time were independent predictive factors of IABP insertion. The postoperative mortality rate was 35.8% and 1% in patients with and without IABP support, respectively (p=0.000). Postoperative renal insufficiency, prolonged ventilatory support, and postoperative atrial fibrillation were independent predictive factors of postoperative mortality in patients with IABP support. The mean follow-up time was 38.55±22.70 months and 48.78±25.20 months in patients with and without IABP support, respectively. The follow-up mortality rate was 3% (n=4) and 5.3% (n=78) in patients with and without IABP support, respectively. CONCLUSION: The patients with IABP support had a higher postoperative mortality rate and a longer length of intensive care unit and hospital stay. The mid-term survival was good for patients surviving the early postoperative period.

Effect of pheniramine maleate on reperfusion injury in brain tissue.

BACKGROUND: The aim of this study was to investigate the protective effects of methylprednisolone (Pn), which is a potent anti-inflammatory agent, and pheniramine maleate (Ph), which is an antihistaminic with some anti-inflammatory effects, on reperfusion injury in brain developing after ischemia of the left lower extremity of rats. MATERIAL AND METHODS: Twenty-eight randomly selected male Sprague-Dawley rats were divided into 4 groups: Group 1 was the control group, Group 2 was the sham group (I/R), Rats in Group 3 were subjected to I/R and given Ph, and rats in Group 4 were subjected to I/R and given Pn. A tourniquet was applied at the level of left groin region of subjects in the I/R group after induction of anesthesia. One h of ischemia was performed with no drug administration. In the Ph group, half of a total dose of 10 mg/kg Ph was administered intraperitoneally before ischemia and the remaining half before reperfusion. In the Pn group, subjects received a single dose of 50 mg/kg Pn intraperitoneally at the 30th min of ischemia. Brains of all subjects were removed after 24 h for examination. RESULTS: Malondialdehyde (MDA) levels of the prefrontal cortex were significantly lower in the Ph group than in the I/R group (p<0.05). Superoxide dismutase (SOD) and glutathione peroxidase (GPx) enzyme activities were found to be significantly higher in the Ph group than in the I/R group (p<0.05). Histological examination demonstrated that Ph had protective effects against I/R injury developing in the brain tissue. CONCLUSIONS: Ph has a protective effect against ischemia/reperfusion injury created experimentally in rat brains.

Axillary artery transection after shoulder dislocation.

Axillary artery transection after shoulder dislocation without bone fracture is extremely rare. Early diagnosis, use of the occlusion balloon for proximal control of axillary artery bleeding, and surgical treatment are important to avoid morbidity and mortality. A 74-year old man presented with a complete transection of axillary artery associated with anterior dislocation of the shoulder without bone fracture. Left axillary artery transection was seen on angiography. An angioplasty balloon was used to prevent bleeding from the subclavian artery. The brachial plexus was compressed by a hematoma. Axillary artery repair was performed with an autologous reversed saphenous vein graft interposition. The patient had palpable distal pulses postoperatively. Motor function was significantly improved but still impaired in the postoperative period. Follow-up at 3 months showed good function of the left arm.Successful management of axillary artery injuries requires prompt diagnosis and surgical treatment. Neurologic injury may affect the functional outcome of the limb.

Effect of 1α-25-dihydroxyvitamin D3 on intimal hyperplasia developing in vascular anastomoses: a rabbit model.

INTRODUCTION: A common problem encountered in routine daily practice of cardiovascular surgery is migration of smooth muscle cells leading to intimal hyperplasia developing at vascular anastomosis sites which then causes luminal narrowing. The aim of this study was to investigate the antiproliferative effect of 1,25 (OH)2D3 on intimal hyperplasia. MATERIAL AND METHODS: Twenty-one male white New Zealand rabbits weighing 2-3 kg were selected. There were 3 groups of animals each consisting of 7 rabbits. Group 1 was the control group. Group 2 was the sham group and group 3 consisted of rabbits receiving 1,25 (OH)2D3. The right carotid arteries of the subjects in groups 2 and 3 were transected and re-anastomosed. A daily dose of 25 ng 1,25 (OH)2D3 per 100 g body weight was administered for 14 days to rabbits in group 3. Rabbits in group 2 were not subject to any pharmaceutical agent. All the subjects were sacrificed at the end of the 28(th) postoperative day. Their right carotid arteries were resected and then investigated histopathologically. RESULTS: Intimal thickness and intimal area were measured as significantly lower in group 1 when compared with the other groups (p = 0.004). In group 3, the ratios of thickness of tunica intima/thickness of tunica media and area of tunica intima/area of tunica media were significantly lower than those of group 2 (p = 0.015, p = 0.003). CONCLUSIONS: 1,25 (OH)2D3, the active metabolite of vitamin D, reduces the intimal hyperplasia developing after vascular anastomoses.

Coronary surgery in patients with low ejection fraction: mid-term results.

BACKGROUND: The aim of this study was to investigate the effect of preoperative low ejection fraction (≤30%) on postoperative morbidity and mortality in patients undergoing isolated on-pump coronary artery bypass grafting. We also investigated the effect of pre- and perioperative factors on survival. METHODS: Between January 2002 and December 2009, 103 (6.2%) patients with an ejection fraction ≤30% and 1554 (93.8%) with an ejection fraction >30% underwent coronary artery bypass grafting. RESULTS: In multivariate logistic regression analysis, cardiopulmonary bypass time, operation time, prolonged inotropic support, and intensive care unit stay were independent predictors of mortality in patients with low ejection fraction. Intensive care unit and hospital stays were significantly longer in these patients, and the postoperative mortality rate was significantly higher. Advanced age (≥70 years) influenced mortality during the follow-up of patients with low ejection fraction. Midterm survival was significantly reduced in patients with ejection fraction ≤30%. Smoking, prolonged inotropic support, and prolonged ventilatory support were independent predictors of midterm survival in patients with ejection fraction ≤30%. CONCLUSION: On-pump coronary artery bypass grafting can be performed in patients with ejection fraction ≤30%, with reasonable mortality and morbidity rates.

Surgical treatment of a giant external-iliac-vein aneurysm in a patient with a post-traumatic femoral arteriovenous fistula.

Iliac vein aneurysm is a rare vascular abnormality. It has been reported as a primary aneurysm of unknown cause, or, when a cause could be identified, as a secondary iliac vein aneurysm. Occasionally, iliac vein aneurysm develops in association with distal arteriovenous fistula. Although venous aneurysms occur most commonly in the neck and central thoracic veins, they also have been reported in the visceral veins and the extremities.Herein, we present the case of a 34-year-old man in whom a giant external-iliac-vein aneurysm was incidentally found during the investigation of a post-traumatic femoral arteriovenous fistula. The aneurysm was surgically resected, the iliac vein was reconstructed by means of lateral venorrhaphy, and the patient had an uneventful, complete recovery. We discuss the origin of the aneurysm and our choice of surgical techniques.

Protective effects of levosimendan and iloprost on lung injury induced by limb ischemia-reperfusion: a rabbit model.

BACKGROUND: The aim of this study was to clarify whether levosimendan could prevent lung tissue injury from limb ischemia/reperfusion. METHODS: The common femoral arteries of 50 New Zealand white rabbits, both male and female, each weighing about 3 kg, were clamped and 1 h of ischemia followed by 4 h of reperfusion. In an attempt to decrease reperfusion injury, the rabbits were given levosimendan in Group A. In Group B, iloprost was infused at the same period. A similar value of saline solution was given in the control group, Group C correspondingly. Levosimendan and iloprost were given together the Group E, and Group D was sham group without medication and ischemia. Blood pH, pO2, pCO2, HCO3, Na, K, creatine phosphokinase, lactate dehydrogenase values were determined at the end of the reperfusion period. Malondialdehyde (MDA) was measured in plasma and lung as an indicator of free radicals. Hemodynamics parameters were noted for each group. After the procedure, left lung tissues were taken for histopathologic study. RESULTS: Blood PO2 and HCO3 levels were significantly higher (P < 0.05) and creatine phosphokinase, lactate dehydrogenase, and MDA levels were significantly lower (P < 0.05) in Groups A, B, D, and E compared with Group C. Similarly, the MDA levels in the lung tissue and plasma levels were significantly lower in the treatment groups compared with the control group (P < 0.05). Lung damage was significantly higher in Group C. There was no significant difference between groups in other parameters. CONCLUSIONS: The results suggest that levosimendan and iloprost are useful for attenuating oxidative lung damage occurring after a period of limb ischemia/reperfusion.

Traumatic brachial artery injuries.

We performed this retrospective study to analyze our strategies for managing and surgically treating brachial artery injuries. Fifty-seven patients with a total of 58 traumatic brachial artery injuries underwent surgery at our institution, from August 1996 through November 2004. Fifty-four patients were male and 3 were female (age range, 7 to 75 years; mean, 29.4 years). Forty-four of the patients had penetrating injuries (18 had stab wounds; 16, window glass injuries; and 10, industrial accidents), 10 had blunt trauma injuries (traffic accidents), and 3 had gunshot injuries. Fourteen patients (24.6%) had peripheral nerve injury. All patients underwent Doppler ultrasonographic examination. The repair of the 58 arterial injuries involved end-to-end anastomosis for 32 injuries (55.2%), reverse saphenous vein graft interpositional grafts for 18 (31%), and primary repair for 8 (13.8%). Venous continuity was achieved in 11 (84.6%) of 13 patients who had major venous injuries. Nine of the 57 patients (15.8%) required primary fasciotomy. Follow-up showed that 5 of the 14 patients with peripheral nerve injury had apparent disabilities due to nerve injury. One patient underwent amputation. There were no deaths. We believe that good results can be achieved in patients with brachial artery injuries by use of careful physical examination, Doppler ultrasonography, and restoration of viability with vascular repair and debridement of nonviable tissues. Traumatic neurologic injury frequently leads to disability of the extremities.

Synchronized coronary revascularization and multiple cardiac cysthydatid operation.

Cardiac cysthydatid is rare pathology and is seen in 0.5 to 2% of echinococcal infections. It is found in the left ventricle most frequently and then in the right ventricle. We present a case with a ruptured cysthydatid at the right atrium's interatrial septum and multiple cysthydatids localized at the outer surface of the left ventricle's apex, which necessitated a synchronized coronary revascularization with our diagnosis and surgical procedure modalities. Our patient was a 61-year-old man with complaints of fever, dyspnea, tachycardia and chest pain, which began 2 months before admittance. An echocardiography in our clinic revealed a 4.7 x 1.7 centimeter, pediculled, going in and out to tricuspidal inflow, cystic mass adherent to the interatiral septum in the right atrium, which prompted immediate hospitalization. He was in New York Heart Association Class II. His electrocardiography (EKG) showed ischemia at inferior and lateral surfaces, so we performed a coronary angiography and determined a severe stenosis at the proximal part of the left anterior descending artery. His EKG showed ischemia at the inferior and lateral surfaces, so we performed a coronary angiography and determined a severe stenosis at the proximal part of the left anterior descending artery. His preoperative biochemical parameters were normal, and cysthydatid serology tests were negative. With these results,l we planned a synchronized surgical procedure for coronary artery disease with multiple cardiac cysthydatids. During operation, after the right atriotomy, a fragile cystic mass with a ruptured image and dimensions of 5 x 2 x 2 centimeters, originating from the interatrial septum and in a conglomerate form, was resected and extirpated. The left atrium was not involved. Then, 3 masses with dimensions of 2 x 2 centimeters, which were not diagnosed with the echocardiogram, at the epicardial surface of the left ventricle apex were excised. The defected part of the left ventricle was repaired with teflon felt supports for rupture prophylaxis. Then, a left internal mammary artery graft, which was prepared at the beginning of the operation, was anastomosed to LAD. The patient didn't have any additional problem during the postoperative period, and he was discharged at 1 week after surgery. To avoid recurrence, the patient was prescribed albendazole as a prophylaxis for the duration of 2 months. Histopathology confirmed the diagnosis of cysthydatid. Patients with cardiac cysthydatid can be asymptomatic or can cause minimal nonspecific symptoms for years. The condition can be lethal if not diagnosed and treated. The primary treatment for cysthydatid is surgery. Echocardiography is an important diagnostic method for cysthydatid. Serological tests can produce negative results if the immune responses of the patient is not sufficient, so it must be remembered in the endemic places for echinococcus.

Recent surgical experience in chronic constrictive pericarditis.

We reviewed the cases of 42 consecutive patients who underwent surgery for chronic constrictive pericarditis between January 1994 and January 2002, to determine causes, surgical techniques, mortality and morbidity rates, and improvement of functional capacity. Thirty-one of our patients were men (73.8%) and 11 were women (26.2%); their average age was 39.3 years. The pericarditis was tuberculous in 24 patients (57.1%), idiopathic in 10 (23.8%), rheumatic in 4 (9.5%), uremic in 2 (4.8%), and neoplastic in 2 (4.8%). In all cases, our approach was via median sternotomy. All anterior pericardium was resected from phrenic nerve to phrenic nerve. In 4 of 18 patients with calcific pericardial plaques, we could not develop a cleavage plane, so we left the plaques in place, reducing their size and relieving constriction by means of wedge incisions that reached the epicardium. No patient required cardiopulmonary bypass due to severe calcification or adhesion, but we did perform bypass with no difficulty in 5 patients who required additional cardiac surgery The early postoperative mortality rate was 11.9% (5 patients). In the 1st postoperative month, functional capacity improved dramatically: the number of patients in New York Heart Association functional class IV moved from 18 (preoperatively) to 1; in class III, from 20 to 6; in class II, from 4 to 13; and in class I, from 0 to 22. We recommend the median sternotomy approach for chronic constrictive pericarditis and consider cardiopulmonary bypass safe to use in indicated cases.