An unexpected image on a chest radiograph.

Introduction Central venous catheterisation is an essential component of patient care in hospital. A forgotten complete guide-wire is a rare complication, although the reported incidence has increased rapidly over the last decade. Case report We report a 72-year-old man with a complete guide-wire inadvertently overlooked during catheter insertion. A central venous catheter had been inserted for total parental nutrition during treatment for pancreatitis. Five years later, the patient was readmitted with a painful lesion on his neck and the sensation of a sharp object under his skin. He was discharged without complication following removal of the free part of the guide-wire that had not become attached to the endothelial layer. Conclusion Inattention, inexperience and lack of supervision by a more experienced clinician are considered the most important contributing factors to this complication. Ultrasonography assistance during the procedure, senior supervision, a set count and a chest X-ray after the procedure are recommended in order to prevent forgotten guide-wires.

Silent killer: A scalpel in the aortic wall after spinal surgery.

Iatrogenic vascular injury during lumbar spinal surgery is rare, but may lead to serious complications in unrecognized cases. Especially, injuries to aorta or its major branches may result in death unless diagnosed and treated immediately. We present a rare case of aortic injury with a scalpel in a 56-year-old male patient undergoing lumbar disk surgery. The vascular injury was successfully treated with open surgery. The post-operative period was uneventful and the patient was discharged in a healthy condition on the 8th day. This case once again reminds us that surgery is always open to complications and that early diagnosis and appropriate interventions are of paramount importance to overcome these complications.

Protective effect of clotrimazole on lung injury in an experimental model of ruptured abdominal aortic aneurysm.

BACKGROUND: Lungs are the target organs most affected by ischemia/reperfusion (I/R) injury, which is exacerbated when hemorrhagic shock occurs. Suppressing various proinflammatory cytokines, inflammation and oxidation that initiate and aggravate lung damage with various drugs or methods provides significant benefits in preventing lung damage. OBJECTIVES: This study aims to evaluate the protective effect of clotrimazole (CLT), an antimycotic drug, on lung injury and systemic inflammatory response in rats by creating an experimental model of a ruptured abdominal aortic aneurysm (RAAA). MATERIAL AND METHODS: Thirty-six male Sprague Dawley rats were randomly divided into 5 groups: sham, sham+CLT, sham+polyethylene glycol (PEG), shock+ischemia/reperfusion (SIR), and SIR+CLT. Saline, CLT and PEG were administered in the sham groups without shock and I/R. The hemorrhagic shock was developed in SIR groups by drawing blood for 1 h to keep the mean arterial pressure at 50 mm Hg. After 60 min, the SIR+CLT group was given 20 mg/kg CLT; then, the aortic clamps were opened, and rats were left for 120 min of reperfusion. The blood taken to create hemorrhagic shock was returned in a controlled manner during this time. At the end of the reperfusion procedure, samples were taken for cytokine levels in serum and lung tissue and for other biochemical analyses. Blood gas, histopathological examination and wet/dry weight measurements were performed to assess lung injury. RESULTS: An increase was observed in all parameters in the SIR group compared to the sham group. In the SIR+CLT group, the serum myeloperoxidase (MPO), tumor necrosis factor alpha (TNF-α), lung MPO values, histologically lung injury scores, and lung tissue wet/dry ratio were decreased significantly when compared to the SIR group (p < 0.05). CONCLUSIONS: These results indicate that CLT may reduce the systemic inflammatory response and lung injury due to shock and I/R in an experimental model of RAAA.

Fourteen-Year Patency of an Anterior Tibial Artery-Saphenous Vein Fistula in an Ambulatory Patient.

Background: Ankle arteriovenous fistulas are the rarest vascular access type among lower extremity fistulas for hemodialysis patients with end-stage renal disease. Here, we present a case of a tibial-saphenous fistula that remained open for a long time despite a recurrent anastomotic aneurysm. Case Presentation. A 43-year-old female patient who had been undergoing hemodialysis via a right femoral tunnel catheter for six months was referred for recurrent catheter infection and a 4 cm pulsatile mass in the anterior aspect of the ankle. While she had been undergoing hemodialysis through a right tibial-saphenous fistula for fourteen years, hemodialysis continued after the fistula's closure due to total occlusion of the great saphenous vein through the tunneled catheter. After balloon angioplasty to the right subclavian vein, we performed right upper extremity basilic vein transposition. Later, after starting adequate dialysis from the basilic vein fistula and removing the femoral catheter, we performed a resection of the anastomotic aneurysm in the right ankle and repaired the anterior tibial artery. Because this is the only ambulatory patient and the one with the longest patency of ankle arteriovenous fistulas in the literature and the only case in which the anterior tibial artery was used, the case is presented and discussed in light of the literature. Conclusion: Despite many complications and low patency rates reported in the literature, ankle vessels should be considered for autogenous vascular access in selected patients.

Extracorporeal membrane oxygenation experiences during COVID-19 pandemic, third wave with younger patients: A retrospective observational study.

OBJECTIVES: In this article, the results of severe coronavirus disease 2019 (COVID-19) cases followed with extracorporeal membrane oxygenation (ECMO) support in a 3-month period in the third wave when there were an increased number of cases of young patients in our intensive care unit (ICU) were presented. METHODS: The study was carried out with all COVID-19 patients who were given ECMO support in our tertiary referral hospital ICU after obtaining the consent of the Ministry of Health Scientific Research Platform and after the approval of the local ethics committee. Patient data were obtained retrospectively from intensive care bedside follow-up charts and computer records. The demographic and clinical characteristics of the patients were presented in average, median, and percentages. The data of the patients were evaluated and compared with the current literature. RESULTS: ECMO treatment was applied in seven patients who were followed up with severe COVID-19 pneumonia in the last 3 months. Venovenous extracorporeal membrane oxygenation (VV-ECMO) was applied to all patients. Five (71.5%) of seven patients were weaned from ECMO. Four (57.2%) of seven patients were discharged from the ICU and hospital in good health. While two of the patients had a cesarean section (C/S) before ECMO, one patient underwent C/S under ECMO. All three newborns were delivered via C/S and all were premature (C/S dates were 35 weeks, 32 weeks, and 27 weeks), and all were discharged from the hospital in good health. CONCLUSION: Our experience shows that ECMO in COVID-19 patients is a lifesaving treatment option that can be successfully applied in severe acute respiratory distress syndrome cases who do not respond to conventional treatments.

Ischemia-modified albumin reduction after coronary bypass surgery is associated with the cardioprotective efficacy of cold-blood cardioplegia enriched with N-acetylcysteine: a preliminary study.

BACKGROUND: The aims of this preliminary study were to determine the alteration of serum ischemia-modified albumin (IMA) levels and to investigate whether IMA may be used as an indicator of the cardioprotective efficacy of N-acetylcysteine (NAC) in patients undergoing coronary bypass grafting (CABG). PATIENTS AND METHODS: Forty-four patients were randomized into one of two groups on the basis of cardioplegic strategies, either cold-blood cardioplegia enriched with NAC (50 mg/kg) or cold-blood cardioplegia alone. Serum IMA, cardiac troponin T (cTnT) and malondialdehyde (MDA) levels determined in NAC-enriched patients before and after CABG were compared with those of the NAC-free group. The albumin cobalt binding assay was used for IMA determination. RESULTS: Serum IMA levels were significantly elevated after cross-clamping and peaked at 6 h after reperfusion in the two groups. In NAC-enriched patients, IMA levels determined 6, 12, 24 and 48 h after reperfusion were significantly lower than those of the NAC-free group (p < or = 0.001, p < 0.001, p < 0.001 and p < 0.001, respectively). IMA returned to baseline 24 h after reperfusion differently from cTnT and MDA in the NAC-enriched group. CONCLUSIONS: IMA may be used as not only an indicator of myocardial ischemia-reperfusion injury, but also as a useful indicator of the cardioprotective effect of NAC in CABG.

Renoprotective potential of exogen erythropoietin on experimental ruptured abdominal aortic aneurysm model: An animal study.

OBJECTIVES: The aim of this study is to investigate the renoprotective effect of erythropoietin (EPO) on hypovolemic shock and ischemia/reperfusion (IR) injury on kidneys as end-organs in an experimentally-created ruptured abdominal aortic aneurysm (rAAA) model. MATERIALS AND METHODS: Thirty anesthetized Sprague-Dawley male rats were randomized to sham ((Sh n:6) (Sh+EPO n:6)) or shock and I/R groups ((S/IR n:9) (S/IR+EPO n:9)). Additional surgical procedure except aortic exploration was not performed on Sh and Sh+EPO groups. 60 min of shock, 60 min of ischemia, and 120 min of reperfusion were applied on S/IR and S/IR+EPO groups. In the S/IR and S/IR+EPO groups, hemorrhagic shock, lower torso ischemia, and reperfusion were created. At the end of the shock period, saline solutions were separately and equally administered to Sh and S/IR groups, whereas 2000 U/kg EPO was intraperitoneally administered to Sh+EPO and S/IR+EPO groups. At the end of the experimental study, some biochemical and histological parameters were studied in serum and kidney tissues. RESULTS: Biochemical parameters were all significantly increased in the S/IR group compared with the Sh group. These parameters were not statistically significantly different between S/IR+EPO and Sh+EPO groups. In histopathologic examination, EPO prevented high-grade injury. CONCLUSION: Our data indicate that EPO may have a renoprotective effect and reduce the systemic inflammatory response that resulted from shock and I/R in an experimental model of rAAA.

Use of the autologous spiral vein graft: a two-stage iliac bypass in a potentially fatal case of pelvic trauma and contaminated tissues.

Serious problems may be encountered in arterial or venous reconstruction in cases of severe trauma and contaminated tissues. We report the use of a spiral venous graft (SVG) in a case of two-stage bypass aimed at saving first life, and then the extremity. Severe open and contaminated injury was present in the lower abdomen and pelvic region of 29-year-old woman brought to the emergency department following a traffic accident. The patient was in shock, and was taken for emergency surgery jointly with the relevant departments. Interposition bypasses with synthetic graft were performed in the first stage. The synthetic grafts were subsequently removed due to problems developing secondary to infection at subsequent follow-up, and revascularization was established with autologous grafts together with SVG. SVGs are alternative grafts in cases with contaminated tissues and requiring major vessel reconstruction. This technique can add to the therapeutic options available.

True Aneurysms of the Extracranial Carotid Artery : An Evaluation of Two "Giant Aneurysms" and the Current Literature.

True extracranial carotid artery aneurysms (ECCAs) are uncommon. Atherosclerosis is the most common etiological factor. Neck pain, a pulsatile mass and murmur at auscultation are the most common symptoms. ECCAs may exhibit severe clinical manifestations due to complications. Cases of rupture can be fatal. There is a risk of distal embolization and stroke in thrombosed cases. We discuss two cases of enlarged ECCA treated surgically in the light of the most recent literature.

Obturator bypass in the treatment of prosthetic graft infection: Classic but still effective.

Aortic graft infection is associated with high mortality and morbidity rates. In this article we report a 60-year-old man who developed bilateral groin wound infection and progressively worsening lower extremity ischemia one year after he underwent aortobifemoral bypass. The infected graft was resected and bilateral obturator bypass was performed. The obturator bypass, an extra-anatomical bypass closest to anatomical position with high patency rates, continues to be favored in revascularization of the lower extremity when the inguinal region should be avoided. Likewise, the obturator bypass is an effective surgical approach against recurrent infections.

Hyperbaric oxygen treatment in thromboangiitis obliterans: a retrospective clinical audit.

INTRODUCTION: Wounds refractory to standard treatment in patients with thromboangiitis obliterans (TAO, Buerger's disease) are associated with amputation, other morbidity and mortality. The purpose of this study was to investigate the effect of hyperbaric oxygen treatment (HBOT) in patients with TAO. MATERIALS AND METHODS: Ninety-seven patients with TAO with ischaemic wounds treated between January 2007 and July 2016 were included in this dual-centre, non-randomised, retrospective study. Patients receiving HBOT in addition to conventional treatment were enrolled in an HBOT group (n = 47) and those receiving conventional treatment alone in a non-HBOT group (n = 50). All patients were Rutherford grade III at the time of enrolment. RESULTS: Significant improvement in the major amputation rate was observed in the HBOT group 10 months after starting treatment (2/47 vs. 13/50, P = 0.007). Numbers of patients progressing to Rutherford grade I (27/47 vs. 17/50, P = 0.035), numbers of patients healing completely (21 vs. 11, P = 0.031 and pain scores (visual analogue scale; 1, range 0-8 vs. 6, range 0-9, P < 0.001) were also significantly improved in the HBOT group. CONCLUSION: The addition of HBOT to conventional treatment in TAO patients with non-healing ischaemic wounds and severe extremity pain, conferred significant benefits in terms of wound healing and rest pain control. Multi-centre, prospective, randomized studies with blinded outcome analysis are now needed to elicit more reliable results.

Emergency coronary bypass surgery in patients under the influence of dualantiplatelet therapy: effects of tranexamic acid and desmopressin acetate

Background/aim: Bleeding in patients undergoing coronary artery bypass grafting (CABG) while using dual antiplatelet therapy (DAPT) is a cause of significant morbidity and mortality. The aim of this study is to examine the perioperative hemostatic effects of tranexamic acid (TnX-A) and desmopressin acetate (Des) in these patients. Materials and methods: This clinical study was planned in a prospective and randomized manner. Fifty-four patients were enrolled and classified into 4 different groups. They were compared in terms of various bleeding and transfusion parameters.Results: No significant differences were observed between the groups in pre/intraoperative data apart from closure times. Plasmin/α-2 antiplasmin complex values in the TnX-A and control groups were significantly higher than those in the Des and TnX-A+Des groups at the end of postoperative drug infusion. Mean duration of closure times, first 3-h and total postoperative amounts of drainage, administered volumes of erythrocyte suspension/fresh frozen plasma, cost of blood products, length of intubation, length of stay in the intensive care unit, and time to discharge were also significantly higher in the Des and control groups.Conclusion: Des had no significant effect on bleeding control and even delayed the hemostatic efficacy of TnX-A. Use of TnX-A infusion alone in these patient groups had a positive effect on hemostasis-related data.

Conservative management of chylothorax after coronary artery bypass grafting.

Chylothorax is a rare sequela to cardiac surgery, associated with high rates of morbidity and mortality. There are various medical and surgical options for its management. We describe 2 cases of chylothorax that developed after coronary artery bypass grafting and were managed successfully with medical therapy alone. Conservative treatment such as we describe aims to reduce chyle flow, to drain the pleural cavity in an effective manner, and to prevent chronic sequelae. Optimal conservative treatment, consisting of nothing by mouth and the administration of a pleurodetic agent, should be started immediately upon diagnosis. In most cases, it reduces the need for reoperation and long-term hospitalization. Prospective randomized controlled trials are nonetheless needed to confirm these assumptions.

Augmentation index and aortic pulse wave velocity in patients with abdominal aortic aneurysms.

BACKGROUND: Abdominal aortic aneurysm (AAA) is a severe disease that can prove fatal. Factors such as advanced age, male gender, family history and cigarette use increase the risk of AAA. These factors associated with AAA development also increase arterial stiffness. Aortic pulse-wave velocity (PWV) was measured as an index of aortic stiffness. The heart rate-corrected augmentation index (AIx@75) was estimated as a composite marker of wave reflections and arterial stiffness. Elevated arterial stiffness increases the risk of development of cardiovascular events and impairs cardiovascular functions. In this study we investigated whether arterial stiffness rises in patients with AAA by measuring aortic PWV and AIx@75 parameters. METHODS: Eighteen patients with AAA (age 69 ± 4 years) and 20 patients with no aneurysm (age 66 ± 6) were included. AAA was diagnosed using computerized tomography. Arterial stiffness was measured non-invasively in all patients using a SphygmoCor device. Aortic PWV and AIx@75 were used as arterial stiffness parameters. RESULTS: There was no significant difference between the two groups in terms of demographic characteristics. AIx@75 (33.2 ± 8.9 vs 25.1 ± 7.8, p=0.008) and aortic PWV (14.8 ± 4.9 vs 10.0 ± 1.7, p=0.002) were significantly elevated in the AAA group compared to the control group. CONCLUSION: Elevated AIx@75 and aortic PWV shows that arterial stiffness increases in patients with AAA.

Role of ethyl pyruvate in systemic inflammatory response and lung injury in an experimental model of ruptured abdominal aortic aneurysm.

OBJECTIVE: The purpose of this study is to evaluate the effect of ethyl pyruvate (EP) on systemic inflammatory response and lung injury in an experimental rat model of ruptured abdominal aortic anurysm (RAAA). METHODS: Anaesthetized 30 Sprague-Dawley male rats were randomized to sham (Sh n : 6) (Sh + EP n : 6) or shock and clamp (S/C) groups (S/C n : 9) (S/C + EP n : 9). In the S/C and S/C + EP groups, hemorrhagic shock, lower torso ischemia, and reperfusion were created, S/C group was given 1 mL saline and S/C + EP group was given 40 mg/kg EP. At the end of reperfusion process some biochemical and histological parameters were studied in serum and lung tissues. RESULTS: An increase was observed in all parameters except interleukin-6 (IL-6) in the S/C group in comparison to the sham groups. In the S/C + EP group, serum myeloperoxydase (MPO), malondialdehyde (MDA), and tumor necrosis factor alpha (TNF-α) as well as lung MPO and MDA values decreased significantly (P < 0.016). In the lung tissues, histological injury scores and lung tissue wet/dry ratio were significantly decreased in the S/C + EP group as compared to the S/C group (P < 0.016). CONCLUSIONS: Ethyl pyruvate may reduce systemic inflammatory response and lung injury which resulted from shock and ischemia/reperfusion in an experimental model of RAAA.

The diagnostic value of ischemia-modified albumin in the diagnosis of aortic pathology.

AIM: To investigate the diagnostic value of ischemia-modified albumin (IMA) in the diagnosis oflpatients with aortic aneurysm. MATERIALS AND METHODS: The study group consisted of 98 patients who presented to our university hospital emergency department with aortic pathology and were definitively diagnosed using spiral tomography. The control group consisted of 101 healthy individuals with similar demographic characteristics. RESULTS: Mean IMA values were 0.89 +/- 0.21 absorbance units (ABSU) in the aortic aneurysm group (P < 0.001), 0.70 +/- 0.12 ABSU in the aortic dissection group (P < 0.001), 0.98 +/- 0.23 ABSU in the aneurysm and dissection group (P < 0.001), 0.84 + 0.16 ABSU in the aneurysm and rupture group (P < 0.001), and 0.87 +/- 0.27 ABSU in the aneurysm, dissection, and rupture group (P < 0.001). Mean IMA value for the subjects in the control group was 0.62 +/- 0.17 ABSU. All the differences between the aortic pathology groups' IMA values and those of the control group were statistically significant (P < 0.001). CONCLUSION: On the basis of the findings from this study, serum IMA levels are higher in patients with aortic pathology compared to healthy individuals. This finding suggests that IMA may help to diagnose aortic pathology, but it requires confirmation by additional clinical studies.

Native valve endocarditis caused by Erysipelothrix rhusiopathiae in an immunocompetent individual.

Infective endocarditis is a very rare clinical form caused by Erysipelothrix rhusiopathiae. It is rarely seen in immunocompetent individuals. Even after surgery it may entail mortality rates as high as 30-40 %. This report describes a case of native valve endocarditis caused by E. rhusiopathiae and cured with crystallized penicillin G and surgery.

Effects of papaverine and carbon dioxide alone or in combination on the blood flow of internal thoracic artery.

OBJECTIVE: The internal thoracic artery is frequently used as an arterial graft for coronary bypass. Spasms of internal thoracic artery may contribute to early myocardial ischemia. To prevent vasospasm and increase the blood flow, some vasodilatory agents (such as carbon dioxide or papaverine) are used. The aim of the study was to evaluate the combined effects of carbon dioxide and papaverine versus either alone on the blood flow of the internal thoracic artery. METHODS: One hundred patients undergoing coronary artery bypass grafting (28 women and 72 men) with similar characteristics were randomly divided into four groups. We used the classic technique without any vasodilatory management before surgery in group 1, papaverine injection into the endothoracic fascia in group 2, and carbodissection technique in groups 3 and 4. Initial free flows of the internal thoracic arteries were measured after cutting of the vessel. After the first measurement, the ITA pedicles were washed with papaverine solution and wrapped with gauze in the first and fourth groups. Blood flow measurements were repeated 15 minutes later in all groups. RESULTS: When vasodilatory management was applied during excision, the blood flows were significantly increased relative to group 1. The mean blood flows reached a significantly higher level in groups 1, 2, 3, and 4 at the second measurements. In groups 2 and 3, the increase at the first measurements compared to the first group's level was continuously high, but no additional increase was observed between the first and second measurements. In groups 1 and 4, regardless of whether a previous vasodilatory management was present, the increases measured at repeated measurements were significant versus each group's first measurements (P < .05). CONCLUSIONS: Vasodilatory management, such as injection of papaverine into endothoracic fascia or carbon dioxide insufflation applied during excision, increased the free blood flows of internal thoracic artery pedicles. Exogenously applied papaverine produces an additional and continuous vasodilatation regardless of whether a vasodilatory intervention was previously applied.