Vascular Tumors of the Neck in Adults: 10-Year Experience in a Tertiary Center.

INTRODUCTION: The diagnosis and management of vascular lesions of the neck is a challenging task that requires a multidisciplinary approach. This retrospective study assesses the single center experience of vascular tumors of the neck. MATERIALS AND METHODS: Patients diagnosed with a vascular tumor and/or a mass in close proximity to the carotid artery were identified from our records over a 10-year period. The demographic characteristics, clinical features, surgical approach, and outcomes were reviewed. RESULTS: Surgical excision of 17 vascular lesions were performed in 16 patients with a mean age of 51.56 ± 17.35 years at the time of operation. Intra- and/or postoperative clinical and histological assessment revealed unilateral glomus caroticum (N = 11), glomus vagale (N = 2), bilateral glomus caroticum (N = 1), cavernous hemangioma (N = 1), and carotid sheath tumor (N = 1). In three patients, internal carotid artery, common carotid artery and vagal nerve were sacrificed to facilitate complete tumor excision. During the follow-up period, no tumor recurrences were observed, and the morbidity and mortality were minimal. CONCLUSION: Preoperative evaluation concerning the size, extent, and anatomical relationships of the tumor thoroughly should be investigated. Multidisciplinary approach involving vascular surgery, otolaryngology, and radiology is preferred to treat these patients for better outcomes. Preoperative embolization in selected cases may decrease estimated blood loss and operative time.

Endovascular Repair of Iliac Artery Aneurysms: A Single Center Experience in 10-Years.

OBJECTIVES: Isolated iliac artery aneurysms (IAAs) are rare, but nonetheless life-threatening when ruptured. The endovascular approach has taken over open repairs in time. The reported data is constituted of a retrospective series. We reviewed our 10-year-long experience with elective endovascular treatment of iliac aneurysms. METHODS: Data regarding 22 patients with 24 IAAs treated with endovascular stent grafting between 2005 and 2015 were reviewed. RESULTS: Twenty-two patients (aged 68.4 ± 9.6 years, range 50-82) with 24 unilateral or bilateral iliac aneurysms were treated. Twenty patients (91%) were male. Two patients with unilateral IAA had prior abdominal aortic aneurysm (AAA) surgical repair. The mean aneurysm diameter was 4.8 ± 2.1 (3.8 to 7.1) mm. Procedural success rate was 100%, only one patient with an iliovenous fistula had periprocedural type II endoleak. Internal iliac artery coil occlusion was applied in 16 of 24 procedures (66%). Thirty-day mortality included one patient (4%). CONCLUSION: Endovascular repair is the preferred approach for isolated IAAs. Because of the retrospective nature of data sets, larger cohorts are necessary for better definition of morbidity and mortality rates.

Staged or Combined Approach for Carotid Endarterectomy in Patients Undergoing Coronary Artery Bypass Grafting: A 5-Year-Long Experience.

BACKGROUND: Optimal surgical approach for patients with hemodynamically significant carotid and coronary disease remains controversial. We analyzed our 5-year experience and compared early and long-term outcome following staged and combined carotid and coronary artery bypass. METHODS: 312 consecutive patients undergoing carotid endarterectomy and coronary artery bypass between 2008 and 2013 were prospectively enrolled in the study. Patients were scheduled for a staged (carotid endarterectomy followed by coronary artery bypass within 1 week) procedure (Group S) unless they were unstable in terms of cardiac status (were deemed to a combined procedure; Group C). All patient data including demographics, risk factors, immediate perioperative events, 30-day, and long-term outcome were prospectively recorded and then analyzed. Groups S and C were compared for pre- and perioperative data as well as immediate, 30-day, and long-term survival. A P value less than .05 was considered significant. Survival analysis was made using Kaplan-Meier method and log-rank test. RESULTS: Group S included 204 patients and Group C included 108 patients. Preoperative demographics and clinical data were similar in the two groups except that preoperative cerebrovascular events were more common in Group C (31.7% versus 22.22%, P = .036) and bilateral carotid disease was more common in Group S. The EuroSCORE was higher in Group C (2.91 versus 2.65, P = .013). Carotid surgery techniques were similar; intraluminal shunting was more frequent in group C than group S (33.33% versus 9.88%, P = .001). Additional cardiac procedures in addition to coronary surgery was predominant in Group C. 30-day neurological adverse event rates, ICU, and hospital stay were significantly higher in Group C. The 30-day mortality was also sigficantly higher in Group C (1.96% versus 4.62%, P = .001). CONCLUSION: Staged and combined surgical approaches yield comparable outcomes. A staged approach may provide a more favorable neurological outcome with significantly reduced need for intraluminal shunting. Long-term outcome is, however, similar.

Midterm results with endovascular approach to abdominal aortic pathologies in Behçet's disease.

BACKGROUND: Vascular involvement in Behcet's disease is rare, but may be at the forefront of the clinical picture with possible life-threatening scenarios. We reviewed our preliminary results with endovascular treatment of abdominal aortic pathologies in Behçet's disease. METHODS: Data regarding seven patients with abdominal aortic pathologies (aneurysm, pseudoaneurysm, and aortoenteric fistula) and Behçet's disease were treated with endovascular stent-grafting between 2002 and 2006. RESULTS: Seven patients (aged, 39.1 ± 9; range, 27-52 years) with a mean aortic diameter of 58.4 ± 6.3 mm received endovascular stent-grafts, two patients being in emergency settings. Two patients were in active disease state. Four tube-shaped, two aorto-bi-iliac, and one aorto-uni-iliac stents were implanted. One patient expired on day 28 with multiorgan failure after emergency stent-grafting owing to enlarging periprosthetic hematoma following open surgery for ruptured aneurysm. Another patient was declined for endovascular therapy owing to hypoplastic aortoiliac vasculature. CONCLUSION: Endovascular approach provides a reasonable alternative to open repair for the treatment of abdominal aortic aneurysms in select cases; however, in emergency settings, endovascular repair may well have an important, but limited, role in select patients with aortoenteric fistulae, it may yet require a surgical intervention.

Combined aortic and mitral valve replacement in a child with mucopolysaccharidosis type I: a case report.

Mucopolysaccaridosis syndromes are metabolic disorders that are inherited in an autosomal recessive pattern, and demonstrate cardiovascular involvement that, on rare occasions, results in surgery. The case is presented of a 12-year-old boy with symptoms and signs of congestive heart failure who was referred to the authors' department for severe mitral and aortic valvular stenosis. The patient was shown to have the somatic characteristics of mucopolysaccharidosis, while urinalysis indicated the presence of chondroitin sulfate B. Mitral and aortic valve replacements were carried out, using bileaflet mechanical valves with a standard median sternotomy and cardiopulmonary bypass. A bileaflet preservation technique was adopted during mitral valve replacement to provide better hemodynamics. Severe cardiac involvement in mucopolysaccharidosis requiring cardiac surgery in pediatrics has been rarely documented. A low-profile bileaflet mechanical valve, enabling a larger-sized valve insertion, is preferred in order to avoid patient-prosthesis mismatch during somatic growth of the patient.

Isolated partial anomalous pulmonary venous connection of the left lung.

Isolated partial anomalous pulmonary venous connection (PAPVC) of the entire left lung is a rare congenital anomaly with incidental diagnosis and vague symptoms, if any, until late adulthood. If left untreated, PAPVC may result in severe right ventricular failure and pulmonary vascular disease. We present the case of a 34-year-old woman with isolated PAPVC of the entire left lung. The patient underwent operation with a side-to-side left atrio-vertical vein anastomosis while on cardiopulmonary bypass and under cardioplegic arrest. She was discharged without complications and with a gradient of 2 mm Hg across the anastomosis. Left-sided PAPVC can be repaired with minimal morbidity and mortality. Surgical correction is warranted when patients are symptomatic or show evidence of right-sided overload due to unpredictability of the natural course. Recent data demonstrate that both on-pump and off-pump surgical procedures produce excellent long-term outcomes when performed without persisting gradients.

Single-stage correction, with extensive pulmonary arterial reconstruction, of a pulmonary arterial sling associated with tetralogy of Fallot.

Pulmonary arterial sling, rare in itself, is even rarer when associated with tetralogy of Fallot. Successful single-stage correction of this combination, with extensive pulmonary arterial reconstruction, has been reported only occasionally. We describe our experience with an 18 month-old girl, showing that extensive reconstruction of both the pulmonary arteries and the right ventricular outflow tract can permit single-stage correction in selected patients, resulting in favourable physiology and anatomy.

Posterior pericardial ascending-to-descending aortic bypass through median sternotomy.

BACKGROUND AND AIM: Adult patients with complex forms of descending aortic disease remain a surgical challenge and have a high risk of postoperative mortality and morbidity. Surgical management may be complicated when there is an associated cardiac defect, necessitating repair, or a hostile anatomy exists. We present our experience with extra-anatomic bypass through posterior pericardial route at the same stage with intracardiac/ascending aortic aneurysm repair. METHODS: Patients that underwent one-stage surgery with posterior pericardial bypass between ascending and descending aorta during 2003-2007 were reviewed. Data from early and mid-term follow-up, including mortality, perioperative blood loss, graft-related complications, patency, and persistent hypertension, were noted. RESULTS: Six male patients with a mean age of 20.8 +/- 0.7 years were operated for coarctation of the aorta associated with additional pathologies (three cases of ascending aortic aneurysm-one with associated aortic valve insufficiency, one case of isolated aortic valve regurgitation, two cases of mitral valve regurgitation). No early or mid-term mortality was observed during follow-up of a mean of 21.6 +/- 10.0 months. No late graft-related complications or reoperations were observed with patent grafts. Systolic blood pressure decreased after surgery by an average of 43 mmHg. CONCLUSIONS: Coarctation of the aorta with concomitant cardiac lesions can be repaired simultaneously through sternotomy and posterior pericardial approach, when patients present in adulthood, to minimize morbidity and mortality.

Mitral valve replacement with bileaflet preservation for complex annular calcification.

Extensive calcification of mitral apparatus may preclude optimal valve repair, thus requiring debridement. We performed mitral valve replacement in a 55-year-old woman with a modified bileaflet preservation technique to avoid complications related to extensive debridement. Posterior transposition of the anterior leaflet as a buttress over the posterior ventricular wall provided extra support for the weakened tissues and covered the decalcified areas, which protected against debris embolism. This technique is safe and reproducible, especially for elderly patients who have complex calcification that requires extensive debridement, enables better preservation of ventricular function, and avoids disruption of the mechanical left ventricular wall.

Comparison of complications and procedural activities of pulmonary artery catheter removal by critical care nurses versus medical doctors.

BACKGROUND: None of the nursing studies on PA catheter removal pointed out any differences in complications after removal and procedural activities for removal of PA catheter by CCNs vs MDs in Turkey. AIMS: This quasi-experimental study was conducted to determine the occurrence and type of complications and to indicate the differences between CCNs and medical doctors' (MDs) activities for removal of PA catheter. METHODS: Totally, 60 critical care unit patients were scheduled as a sample, and they were assigned randomly to the CCN (n = 30) or to the MD (n = 30) groups. For the comparison purposes of the different activities and complications of PA catheter removal procedure between the two groups, 'Instruction Form' was followed step by step. The differences in the prevalence of variables were tested using Student's t statistics. For categorical data, Fisher's exact test was used. Significance was declared by P value of <0.05. RESULTS: Preprocedural activities like patient positioning (P < 0.001) and instructing the patient for breathing (P = 0.001) demonstrated statistically significant differences between the two groups. The PA catheters were removed properly in both groups (P > 0.05). The majority of postprocedural activities were completed successfully. The complications of the catheter removal were documented more carefully by nurses compared with doctors (P < 0.01). Additionally, singular premature ventricular complexes were observed on electrocardiogram in both groups (P > 0.05). CONCLUSION: Instructing CCNs to remove a PA catheter has been highlighted in keeping the number of complications associated with removal procedure of PA catheter.

Midterm results with drug-coated balloons for SFA lesions in patients with CLI: comparison with conventional bypass surgery.

BACKGROUND: Endovascular treatment of symptomatic peripheral artery disease has gained widespread acceptance. The efficacy and safety of drug-coated balloon (DCB) angioplasty in the setting of critical limb ischemia in comparison to conventional surgery has not been demonstrated. We have compared our results with DCB angioplasty to conventional bypass surgery in patients with critical limb ischemia (CLI). METHODS: A total of 187 patients with CLI treated over a 6-year period between 2006 and 2012 by a single operative team constituted the study population. Between 2006 and 2009, all patients underwent conventional surgery. Between 2009 and 2012, the investigators adopted endovascular approach with the use of IN.PACT Admiral (Medtronic Inc., Santa Rosa, CA, USA). Data collection was achieved prospectively. RESULTS: A total 210 procedures (100 surgery, 110 endovascular) were performed over a 6-year period. A 72% of all bypasses were performed using saphenous vein grafts with above-the-knee bypass as the technique of choice in 80% of the cases. 6-mm DCB was used in 41% of the patients. Procedural success rates (98% vs. 99%, NS) as well as clinical success rates (99% vs. 99%, P=NS) and operative mortality (3.7% vs. 2%, NS) was similar in both groups. Primary patency for DCB vs. bypass groups 91.8% vs. 88.9%, respectively (P=0.31) at 12 months and 82.7% vs. 82.8% at 24 months, respectively (P=0.28). Freedom from clinically-driven target lesion revascularization at 12 months was similar in both groups (87.6% vs. 85%, P=0.33). Primary patency for DCB vs. bypass groups at 24 months was 82.7% vs. 82.8%, respectively (P=0.28). CONCLUSIONS: DCB angioplasty yields comparable results to surgery in the setting of critical ischemia. The efficacy and the safety of DCBs in more complex lesions is to be investigated with randomized trials.

Coarctation of the aorta associated with left subclavian artery aneurysm: a case report.

Aneurysm of the left subclavian artery (LSA) in association with coarctation of the aorta (CoAo) is a rare phenomenon, especially in the younger population. A 19-year-old male patient was admitted for lower extremity varices and diagnosed to have severe CoAo and a 45-mm LSA aneurysm after digital subtraction angiography following detection of nonpalpable lower extremity pulses on physical examination. Corrective surgery was performed from a left posterolateral thoracotomy through the 4th intercostal space, and a discrete ring-like coarctation tissue was observed in the aorta just below the level of the LSA orifice. Complete excision of the coarctation tissue was followed by aortoplasty with a Dacron patch. Additionally, the subclavian aneurysm was completely excised and a 10-mm Dacron tube graft interposition was performed. Prompt diagnosis and surgical treatment in particularly hypertensive patients precludes significant mortality and morbidity following a possible rupture.

Effects of low-dose milrinone on weaning from cardiopulmonary bypass and after in patients with mitral stenosis and pulmonary hypertension.

The phosphodiesterase inhibitor milrinone is usually preferred in patients with pulmonary hypertension and myocardial dysfunction after cardiopulmonary bypass. We investigated the effects of low-dose milrinone on pulmonary hypertension in the immediate pre- and postoperative period. Forty-seven patients were randomized to the control and milrinone groups. All patients had mean pulmonary artery pressure greater than 30 mmHg and pulmonary capillary wedge pressure greater than 20 mmHg and were candidates for mitral valve replacement for rheumatic mitral stenosis. Twenty-four patients received a loading dose of milrinone 25 microg/kg(-1) during weaning from cardiopulmonary bypass, followed by a maintenance dose of 0.25 microg/kg(-1)/min(-1) to the end of the surgery. Cardiac output and other hemodynamic variables were noted at induction, weaning from bypass, and postoperative 1 h. Pulmonary artery pressure, capillary wedge pressure, and central venous pressure were significantly lower in the milrinone group during weaning after cardiopulmonary bypass, while other variables were roughly similar. However, patients in the control group required higher doses of vasodilators, inotropes, and antiarrhythmic agents. Mean arterial pressure in the milrinone group was significantly lower at 1 h postoperatively than in the control group; however, the patients did not need many more vasopressors. Fluid restriction and diuretic agent use were more significant in the control group. Systemic arterial hypotension and vasopressor requirements with milrinone use at inotropic doses were not observed at the doses used for the study. A total of 21.7% of the patients in the control group required vasopressors in the perioperative period. Both groups demonstrated similar hematologic variables except that the hemoglobin level in the control group was significantly lower during postoperative days 1 and 7. Low-dose milrinone for a short-term during weaning from cardiopulmonary bypass may be used in patients with mitral stenosis and pulmonary hypertension for its effects on pulmonary artery pressures, less inotropic and vasopressor requirements, and fluid balance.

Effects of propofol and midazolam on lipids, glucose, and plasma osmolality during and in the early postoperative period following coronary artery bypass graft surgery: a randomized trial.

It is not clear how levels of serum lipids and glucose and plasma osmolality change during propofol infusion in the pre- and postoperative period of coronary artery bypass graft surgery (CABG). This prospective, randomized, controlled trial evaluated changes in these parameters during propofol or midazolam infusion during and in the early postoperative period following surgery. Twenty patients undergoing CABG were randomized preoperatively into two groups: 10 patients received propofol (induction 1.5 mg/kg, maintenance 1.5 mg kg(-1) h(-1)) and 10 patients received midazolam (induction 0.5 mg/kg, maintenance 0.1 mg kg(-1) h(-1)). Both groups also received fentanyl (induction 20 mug/kg, maintenance 10 microg kg(-1)). Serum lipids, glucose, and plasma osmolality were measured preinduction, precardiopulmonary bypass, at the end of cardiopulmonary bypass, at the end of surgery, and 4 and 24 h postoperatively. In the propofol group, we observed a significant increase in triglycerides and very low-density lipoprotein levels 4 h postoperatively. In the midazolam group, we observed a significant decrease in low-density lipoprotein, cholesterol at the end of cardiopulmonary bypass, end of surgery, and 4 and 24 h postoperatively and significant increase in osmolality at the end of cardiovascular bypass. Changes in glucose levels did not differ significantly different between the two groups. In patients with normal serum lipids, glucose, and plasma osmolality undergoing CABG, propofol infusion for maintenance anesthesia is not associated with dangerous changes in serum lipids, glucose, and plasma osmolality compared with midazolam. A propofol infusion technique for maintenance of anesthesia for cardiac surgery where serum lipids and glucose may be of concern could be recommended as an alternative to midazolam.

Postoperative effects of opioid analgesics administered via continuous perfusion and patient controlled analgesia after open heart surgery.

Critical care nurses and physicians are familiar with the principles of patient controlled analgesia and the opioid analgesics' regimens and observations necessary for pain control in the postoperative cardiac surgical patients. The objective of the study was to compare the effects of morphine, fentanyl, meperidine, remifentanil and tramadol which were administered by patient controlled analgesia and continuous intravenous infusion combination on the various parameters. This study was designed as prospective randomised trial. Fifty patients undergone open heart surgery with sternotomy were entered equally into five randomized groups. Visual analog scale was used by researcher nurse to assess the patient' pain status. Respiratory rate, heart rate and blood gases (pO2, pCO2, SaO2), radial arterial blood pressures were measured in the first 24 hrs postoperatively. Bolus requirements were determined by physicians and side effects of the analgesics were documented. Fentanyl group showed statistically higher levels of mean pO2 (p=0.002). Meperidine had the lowest number of bolus doses (p=0.001). There were no significant differences between the groups for pain management except higher visual analog scales on tramadol. Headache, stomach-ache and, palpitations were observed in our patients. Remifentanil, meperidine, fentanyl and morphine showed similar effect with each other for pain relief except tramadol.

Fast-track recovery in noncoronary cardiac surgery patients.

OBJECTIVE: Fast-track recovery protocols result in shorter hospital stays and decreased costs in coronary artery bypass grafting (CABG) surgery. However, data based on an objective scoring system are lacking for the impact of these protocols on patients undergoing cardiac surgery other than isolated CABG. METHODS: Between March 1999 and March 2003, 299 consecutive patients who underwent open cardiac surgery other than isolated CABG were analyzed to evaluate the safety and efficacy of fast-track recovery. The parameters evaluated as predictors of mortality, ie, delayed extubation (>360 minutes), intensive care unit (ICU) discharge (>24 hours), increased length of hospital stay (>5 days), and red blood cell transfusion, were determined by regression analysis. Standard perioperative data were collected prospectively for every patient. RESULTS: Seventy-two percent of the patients were extubated within 6 hours, 87% were discharged from the ICU within 24 hours, and 60% were discharged from the hospital within 5 days. No red blood cells were transfused in 67% of the patients. There were no predictors of mortality. The predictors of delayed extubation were preoperative congestive heart failure (P = .005; odds ratio [OR], 4.5; 95% confidence interval [CI], 1.6-12.6) and peripheral vascular disease (P = .02; OR, 6; 95% CI, 1.9-19.4). Factors leading to increased ICU stay were diabetes (P = .05; OR, 3.6; 95% CI, 1-12.6), emergent operation (P = .04; OR, 6.1; 95% CI, 1.1-33.2), red blood cell transfusion (P = .03; OR, 2.9; 95% CI, 1.1-7.8), chest tube drainage >1000 mL (P = .03; OR, 3.4; 95% CI, 1.1-10.2). The predictors of increased length of hospital stay were ICU stay >24 hours (P = .001; OR, 5.9; 95% CI, 2-17), EuroSCORE >5 (P = .05; OR, 1.8; 95% CI, 1-3.2), and chronic obstructive pulmonary disease (P = .003; OR, 3.7; 95% CI, 1.5-8.7). Predictive factors for transfusion of red blood cells were diabetes (P = .04; OR, 2.9; 95% CI, 1.1-8.1), delayed extubation (P = .02; OR, 2.7; 95% CI, 1.4-5.1), increased ICU stay (P = .04; OR, 2.6; 95% CI, 1-6.4), and chest tube drainage >1000 mL (P = .001; OR, 4.3; 95% CI, 2-9.3). CONCLUSIONS: This study confirms the safety and efficacy of the fast-track recovery protocol in patients undergoing open cardiac surgery other than isolated CABG.

A modified combined approach to operative carotid and coronary artery disease: 82 cases in 8 years.

BACKGROUND: A significant number of patients undergoing coronary artery surgery have severe carotid artery disease. It is also true that up to half of the patients undergoing carotid endarterectomy (CEA) have severe treatable coronary lesions. This study aims to review data regarding 82 patients of combined approach in 8 years; the second half consists of 44 patients whose CEA was performed under local anesthesia. It compares results of the conventional and the modified approaches to simultaneous surgery. METHODS: All 82 patients who planned to have a concomitant procedure were recorded prospectively between 1995 and 2003. From 1998, the surgical technique has been modified to switch to local anesthesia for CEA, rather than perform under a single general anesthetic period. All pre-and perioperative data as well as in-hospital and outpatient control (mid- to long-term) data were recorded. A P-value of less than .05 was considered as significant. Analysis of survival was performed by using the Kaplan-Meier method and the log-rank test. RESULTS: The 30-day follow-up was 100% complete for all patients. All patients were followed for 59.59 to 114 months) months postoperatively. Three patients (6.8%) in the modified and 2 (5.2%) in the standard group had intraluminal shunting (P > .05). In the standard group, 3 patients expired and 3 had perioperative stroke; only 1 patient had a stroke in the modified group and two expired (P > .05). Mean survival time according to Kaplan-Meier test was 109.97, SE 2.84, 95% CI (104.41-115.52) months for the former group, whereas it was 62.79, SE 1.20, 95% CI (60.4565.13) months for the latter. Actuarial estimates of survival during ten-year follow up were 94.44% SE 3.83 in ten-year follow-ups and 97.67% SE 2.30 in 5-year follow-ups for the modified group (P > .05). CONCLUSIONS: Avoidance from extended periods of general anesthesia and cardiopulmonary bypass periods as well as immediate recognition of impaired cerebral flow during CEA and the time it provides to take preventive measures are the most important benefits of the modified technique without significantly changing hospital and long-term mortality and stroke. It may also reduce the cost and the waiting period for the suffering patient.

Comparison of antihypertensives after coronary artery surgery.

Hypertension following coronary artery bypass grafting is a common problem that may result in postoperative myocardial infraction or bleeding, Hemodynamic effects were compared in 45 hypertensive coronary bypass patients randomized to receive either diltiazem, nitroglycerin, or sodium nitroprusside. Diltiazem was administered as an intravenous bolus of 0.3 mg.kg-1 within 5 min, followed by infusion of 0.1-0.8 mg.kg-1.h-1 in group 1. Nitroglycerin was infused at a rate of 1-3 microg.kg.h-1 in group 2, and sodium nitroprusside was given at a rate of 1-3 microg.kg-1.min-1 in group 3. Hemodynamic measurements were carried out before infusion (T1) and at 30 min (T2), 2 h (T3), and 12 h (T4) after initiation of treatment in the intensive care unit. Mean arterial pressure decreased significantly in all groups. There were no differences among groups at T1 and T2. At T3, heart rate in group 2 was significantly higher than group 1. At T3 and T4, the double product was highest in group 3 (group 1 vs. 3, p<0.001). These results suggest that the hemodynamic effects of the 3 drugs are similar within the first 30 min. However, after 30 min, diltiazem affords better myocardial performance and more effective control of hypertension.

Midterm Results Following Percutaneous Rotational Thrombectomy for Acute Thrombotic Occlusions of Prosthetic Arteriovenous Access Grafts.

Patent vascular access is critical for patients on regular hemodialysis. Prosthetic grafts are good alternatives when the superficial venous system is of poor quality. However, thrombosis is one of the main drawbacks of synthetic grafts, with reports of 59% to 90% patency rates for 1 year. In cases of thrombotic occlusion of prosthetic arteriovenous fistula grafts, percutaneous mechanical thrombectomy has recently gained clinical popularity as a potential alternative to surgical thrombectomy or pharmacologic thrombolysis. We reviewed our preliminary results from 30 percutaneous rotational thrombectomies performed in a total of 22 patients in the setting of acute dialysis-access prosthetic graft occlusion of the upper extremity. Among the 30 cases of acute occlusion of the arteriovenous graft, immediate success with angiographic flow restoration was observed in all patients except for 2 patients (both females; 6%), with de novo occlusion where reocclusion occurred within 12 hours despite apparent immediate angiographic patency. The mean duration between the initial presentation with acute arteriovenous graft occlusion and the thrombectomy procedure was 27.4 ± 12.4 hours. The mean duration of graft patency was 10.45 ± 0.6 months. A total of 75% of the arteriovenous grafts were patent at the end of 12 months of follow-up. Female gender, diabetes mellitus, and diagnosis to intervention interval were reviewed for midterm graft failure, and the presence of diabetes mellitus yielded significance (P < 0.05). Percutaneous techniques play important roles in the treatment of failed or failing arteriovenous fistulae and grafts. Ongoing analysis of outcomes of both percutaneous and surgical intervention is necessary to continue to identify optimum treatment algorithms.