A new percutaneous technique: N-butyl cyanoacrylate adhesive for the treatment of giant saphenous vein insufficiency.

Background We have made a retrospective evaluation of the results of the cyanoacrylate ablation technique which has recently started to be used in the treatment of giant saphenous vein insufficiency today and in which tumescent anesthesia is not required. Methods Giant saphenous vein was treated in 50 patients between September 2015 and September 2016 by using endovenous cyanoacrylate ablation. In the procedure, tumescent anesthesia and varsity socks were not used. Control duplex ultrasound evaluation was performed in the post-procedural 1st, 6th and 12th months. Venous Clinical Severity Score and Aberdeen Varicose Vein Questionnaire scores were evaluated. Results In the 50 patients who were treated, full closure was observed in giant saphenous vein in 47 (94%) patients in the 12th month control duplex ultrasound. The mean age of the patients was 46.4 (20-70) and 30 (60%) of them were female. The median Venous Clinical Severity Score scores in the 1st, 6th and 12th months were 3, 2 and 1, respectively ( p < 0.001); the median Aberdeen Varicose Vein Questionnaire scores in the 1st, 6th and 12th months were 7, 5 and 4, respectively ( p < 0.001). In the access site, two (4%) patients developed phlebitis and one (2%) developed ecchymosis. However, deep venous thrombosis, pulmonary embolism and paresthesia were not observed. Conclusion Considering the early period results in the treatment of giant saphenous vein insufficiency, cyanoacrylate ablation makes a more reliable alternative than endovenous thermal ablation methods in that it does not require tumescent anesthesia and it has a low incidence of adverse effects.

Crossover femoropopliteal bypass: single graft or double grafts.

BACKGROUND: Both single-graft crossover femoropopliteal (COFP) bypass and crossover femorofemoral plus femoropopliteal bypasses using double grafts may be performed for patients with a medical history of abdominal vascular operations or comorbidity, thereby ineligible for retroperitoneal or transperitoneal approaches. In this study, these two methods were compared. METHODS: A total of 15 patients who were operated on between February 2002 and March 2010 were included and studied retrospectively. Eight of them underwent crossover femorofemoral bypass plus femoropopliteal bypass with double grafts (group 1), whereas the rest seven underwent single-graft COFP bypass (group 2). All the patients were included either in class 3 or class 4 according to Fontaine classification. Preoperative arterial Doppler ultrasound and arteriography were obtained from every patient. Pre- and postoperative ankle-brachial indices were measured. Postoperative clinical parameters were obtained from medical records. RESULTS: Median primary and secondary patency rates were 40.5 (7-105) months and 58 (7-105) months in group 1, respectively. In group 2, these rates were 42 (2-84) months and 44 (11-84) months, respectively. Two patients in group 1 and one patient in group 2 were amputated. There were no significant differences between both groups in terms of duration of hospital stay, duration of intensive care unit stay, and units of packed red blood cells transfused (P > 0.05). In addition, postoperative ankle-brachial indices were significantly improved in both groups (P < 0.05). COFP bypass can be performed for limb salvage in cases with critical limb ischemia with a medical history of previous vascular surgery or comorbidity, thereby ineligible for aortic reconstruction. CONCLUSION: This procedure may also be performed as continuous COFP bypass using a single graft.

[Prognostic factors for hospital mortality in patients with acute mesenteric ischemia who undergo intestinal resection due to necrosis]. / Nekroz nedeniyle bagirsak rezeksiyonu uygulanan akut mezenterik iskemili olgularda hastane mortalitesi için prognostik faktörler.

BACKGROUND: The purpose of this study was to review our experience in patients with acute mesenteric ischemia (AMI) and to identify prognostic factors associated with hospital mortality. METHODS: Clinical data of patients with AMI were reviewed and analyzed retrospectively. A total of 67 patients (34 female, overall mean age 66 years) were evaluated in the study. RESULTS: Small bowel necrosis was detected in all patients, while colonic involvement was present in 21 (31.3%). Necrosed small bowels were resected in 59 (88%) in the first intervention. Embolectomy was also performed in 2 (3%) of these cases. Anastomosis was established in 22 (32.8%). Second-look operation was performed in 31 (46.3%) and primary resection and re-resection were performed in 8 (11.9%) and 11 (16.4%) patients, respectively. Hospital mortality rate was 56.7% (n=38). Logistic regression analysis showed prolonged symptom duration (>24h) (p=0.000), sepsis (p=0.022) and colonic necrosis accompanied with small bowel necrosis (p=0.002) as the independent prognostic factors in hospital mortality. CONCLUSION: AMI has a high hospital mortality rate due to late diagnosis and sepsis. Another risk factor is colonic involvement. Early evaluation in high-risk patients and resection for necrosed intestinal segments as soon as possible prior to sepsis may reduce the hospital mortality rate.

[Traumatic extracranial carotico-juguler fistulation]. / Travmatik ekstrakraniyal karotiko-juguler fistüller.

BACKGROUND: Extracranial caroticovenous fistulae, if left untreated, may cause stroke, cerebral edema, and high output cardiac failure and may present with oculofacial signs. In this study, 5 cases with extracranial arteriovenous fistulae who were diagnosed and surgically treated promptly after trauma are presented. METHODS: Five patients with extracranial traumatic caroti-cojuguler fistulation underwent urgent surgery in our department. Their mean age was 32.4 (range: 27-38). Mean door to operating room time was 2.4 hours. One patient underwent arcus aortography due to a large hematoma in the mediastinum. One patient underwent arterial Doppler ultrasound examination. The remaining three patients were diagnosed via physical examination. RESULTS: There were three gunshot and two stab wounds. The right common carotid artery was injured in three cases and left common carotid artery in two. There was no early or late mortality. Cross-clamp time was 14.3+/-4.7 minutes. There was no major bleeding. One patient developed ischemic stroke secondary to hypotension due to massive bleeding before surgery and was transferred to the Department of Neurology on the 5th postoperative day. CONCLUSION: We suggest that as soon as the diagnosis of traumatic caroti-cojuguler fistula is made, a surgical approach is effective and safe and may prevent possible complications due to delayed diagnosis and treatment.

Repair of post-infarct ventricular septal rupture with an infarct-exclusion technique: early results.

BACKGROUND: Ventricular septal rupture is a rare but life-threatening complication of acute myocardial infarction. The mortality rate with medical treatment is more than 90%, whereas the mortality rate after surgical repair varies between 19% and 60% in different studies. This study reviews our experience based on early closure of the septal rupture with an infarct-exclusion technique. METHODS: Eighteen consecutive patients who underwent post-infarct ventricular septal rupture operation between June 1, 2000, and November 1, 2005, were included in the study. There were 12 male and 6 female patients. Mean age was 65.72 +/- 5.21 years. All patients had echocardiography and coronary angiography before the operation. Rupture was closed with an infarct-exclusion technique in all patients. Preoperative, operative, and postoperative information were collected from patient cohorts. RESULTS: The median time from myocardial infarction to diagnosis of the ventricular septal rupture was 4.22 +/- 1.61 days. Fourteen of the patients had intra-aortic balloon pump support, and 5 had mechanic ventilator support preoperatively. Surgical repair was done 1 to 4 days after the diagnosis. Ten anterior and 8 posterior ventricular septal ruptures were found. Additional coronary artery bypass surgery was performed with a median of 1.27 +/- 0.8 grafts in 15 (83.3%) patients. The mean postoperative mechanic ventilator support time was 34.13 +/- 45.11 hours. Overall 30-day mortality was 16.7% with 3 patients. The mean intensive care unit stay was 3.3 +/- 1.6 days. Postoperative transthoracic echocardiography showed minimal residual shunts in 4 patients. CONCLUSION: Patch closure of the ventricular septal rupture with an infarct-exclusion technique provided acceptable results. Concomitant coronary artery bypass grafting might be beneficial to control additional risk of an associated coronary artery lesion. Prompt diagnosis followed by early surgical intervention is essential for patients with ventricular septal rupture.

Surgical treatment of postinfarction left ventricular pseudoaneurysms.

OBJECTIVE: Left ventricular pseudoaneurysm is a rare but serious complication of acute myocardial infarction. It is under debate whether surgical intervention is mandatory in asymptomatic patients. The aim of this report was to present our experience based on surgical treatment and midterm outcomes of patients with postinfarction left ventricular pseudoaneurysm. METHODS: Eight consecutive patients who underwent left ventricular pseudoaneurysm operation between January 1, 1995, and January 1, 2006, were included in the study. There were 5 male and 3 female patients. Mean age was 62.87 +/- 5.03 years. All patients had echocardiography and coronary angiography before the operation. Two anterior and 6 posterior pseudoaneurysms were detected. Left ventricular pseudoaneurysm was repaired with a synthetic patch by the remodeling ventriculoplasty method of Dor in all patients. Coronary revascularization was performed if necessary. Preoperative, operative, and postoperative data were collected from the patient cohorts. RESULTS: The mean duration from myocardial infarction to diagnosis of the ventricular septal rupture was 13.5 +/- 12 days. Additional coronary artery bypass surgery was performed with a median of 1.2 grafts in 5 patients (62.5%). The mean postoperative mechanic ventilator support time was 20.12 +/- 29.22 hours. Overall 30-day mortality was 12.5% with 1 patient death. The mean intensive care unit stay was 3.75 +/- 2.1 days. The late mortality rate was 12.5%. In the follow-up period (mean, 30.66 +/- 16.86 months), of the 6 patients who were alive, 5 were in New York Heart Association class I or II and 1 was in class III because of pre-existing low left ventricular ejection fraction. Transthoracic echocardiography showed good left ventricular configurations without a false aneurysm together with increases in the ejection fractions. CONCLUSION: Prompt diagnosis and early surgical intervention is essential for patients with large or expanding left ventricular pseudoaneurysms due to the high propensity of fatal rupture. Associated coronary artery bypass grafting may reduce early mortality of patients with left ventricular pseudoaneurysm by resuscitating the ischemic myocardium.

Passive infusion: a simple delivery method for retrograde cardioplegia.

Some damage to the capillaries and increase in myocardial edema have been shown when retrograde cardioplegia perfusion pressure exceeds 40-50 mmHg, or possibly when it falls within this pressure interval. To avoid these complications, we designed a very simple delivery method for retrograde cardioplegia: passive continuous infusion by gravitational force alone. From August 2002 through April 2003, 147 patients undergoing elective coronary artery bypass surgery were randomly allocated into 2 groups. In both groups, isothermic blood cardioplegic solution was infused continuously in a retrograde fashion, after antegrade cardioplegic arrest. Group 1 (n=76) received retrograde infusion passively by gravitational force, while Group 2 (n=71) received retrograde infusion from a manually controlled pressure bag, with the pressure maintained at about 40 mmHg. Myocardial biopsy specimens were taken just before the aorta was declamped, and myocardial edema was scored upon histopathologic examination. Postoperative myocardial damage was evaluated with periodic measurements of CK-MB isoenzyme and cardiac troponin T levels. We recorded cardioplegic infusion pressures and rates, and the total amount of potassium administered. The mean cardioplegic infusion pressures and rates, total potassium levels, and cardioplegic solution amounts were significantly lower in Group 1 than Group 2. Histologic observations revealed significantly less myocardial edema in Group 1. There were no differences between groups in CK-MB isoenzyme or cardiac troponin T levels, mortality, or morbidity. Retrograde continuous infusion of isothermic blood cardioplegic solution by gravitational force alone appears to provide satisfactory myocardial protection and to eliminate the harmful effects of higher pressures upon the myocardium.

An alternative surgical procedure for a patient with critically restenosed and kinked carotid artery: graft interposition.

According to the literature data, the prevalence of restenosis after carotid endarterectomy ranges between 6 and 36%. The etiological factor is intimal hyperplasia for early period, whereas it is atherosclerosis for late period. A 67-year-old male patient admitted to our clinic with a history of headache and minor stroke. His medical history was significant for right carotid endarterectomy 8 years ago. Recent Doppler ultrasound and digital substraction angiography revealed 75% stenosis and kinking corresponding to the segment distal to the endarterectomy region. Surgical endarterectomy is the treatment of choice in critical carotid stenosis. Endovascular therapy is primarily considered for patients if there is restenosis after carotid endarterectomy. However, the treatment modality is controversial in cases with concomitant carotid stenosis and kinking of internal carotid artery. We present our surgical approach to a case with significant stenosis and kinking of internal carotid artery. We performed a 6-mm-PTFE graft interposition between common and internal carotid artery and resection of the kinking segment.

Delayed sternal closure: an effective procedure for life-saving in open-heart surgery.

OBJECTIVE: To determine the incidence, short term survival and safety of delayed sternal closure following open-heart operation due to myocardial edema, non-surgical bleeding and malignant arrhythmia. METHODS: We retrospectively reviewed our medical records to identify the patients who underwent delayed sternal closure following open-heart operation and recorded morbidity, mortality postoperative complications of these patients. Among 2698 patients who underwent on- pump cardiac surgery, the sternum was left open in 46 (1.7%) patients, 31 men and 15 women, ranging in age from 2 to 73 years (mean 57.0+/-7.6 years). In 39 patients sternum was left opened following the initial operation and in 7 patients sternum was re-opened due to bleeding or hemodynamic instability after initial surgery. Statistical analysis was accomplished using Chi-square test, Mann Whitney U test and analysis of variances for repeated measurements. RESULTS: The operative procedures were classified as elective in 24 (52.8%), emergency in 10 (22%), urgent in 7 (15.4%), and redo cardiac operations in 5 patients (11%). Bleeding (n=21), hemodynamic instability (n=16), arrest (n=5), and arrhythmia (n=4) were the reasons of delayed sternal closure. The patients had an open sternum for 3.48+/-0.35 days. Time to discharge was 21.5+/-1.6 days after operation and 17.6+/-1.6 days after sternal closure. Mortality within 30 days was 23.9% (7 patients died before closure and the remaining 4 after closure). Complications were mediastinitis (n=2), minor wound infection (n=3) and renal failure (n=5). CONCLUSION: Delayed sternal closure is a safe and simple method for treating bleeding, arrhythmia and myocardial edema following on pump cardiac surgery. It is anticipated that as cardiac surgeons become more familiar with the technique of delayed sternal closure, the frequency of its use following on pump cardiac surgery may increase.

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.

The influence of levosimendan and iloprost on renal ischemia-reperfusion: an experimental study.

The effects of iloprost on ischemia-reperfusion injury have been studied on the skeletal, muscle, liver, myocardium, kidney, and spinal cord. However, no sufficient data exist about effects of levosimendan on renal ischemia-reperfusion injury. The purpose of this experimental study was to investigate and compare effectiveness of levosimendan and iloprost on renal injury induced by ischemia and reperfusion. Fifty rabbits were divided into five groups. Levosimendan was continuously infused starting half an hour before the cross-clamp. Cross-clamp time was one hour. After one hour ischemia, levosimendan was continued for 4 h in Group A whereas Group B took iloprost in the same protocol. Group C was the control group which did not receive any medication. Group D was sham group and Group E was medicated both iloprost and levosimendan. Renal tissues were histologically and biochemically evaluated. The histological scores were obtained according to presence of tubular necrosis and atrophy, regenerative atypia, hydropic degeneration (Group A vs. Group C<0.001, Group B vs. Group C<0.001, Group D vs. Group C<0.01, Group E vs. Group C<0.001). Mean malondialdehyde levels were 114+/-12 nmol/g tissue; in Group A 121+/-13 nmol/g tissue, in Group B 134+/-13 nmol/g tissue, in Group E 130+/-11 nmol/g tissue, in Group D 134+/-11 nmol/g tissue (Group A vs. Group B; P=0.003, Group B vs. Group D; P=0.132, Group A vs. Group E; P=0.132). Malondialdehyde levels and histologic scores of all of the groups were significantly different from the control group. Iloprost and pentoxyfillin reduced renal ischemia-reperfusion injury in rabbit model. There was no significant difference between these two medications.

Bypass grafting for infrapopliteal occlusive disease with poor distal flow on angiography.

OBJECTIVE: We aimed to investigate whether limb-salvage bypass operation improves outcomes in patients with critical infrapopliteal ischemia and poor or no distal arterial flow on angiography. METHODS: Forty-nine patients with severe tibial and peroneal occlusive disease and poor distal arterial flow on angiography were included in this prospective study. The age ranged from 57 to 82 years in the surgical group and 63 to 80 in the medical group. Patients had class III or IV disease according to Fontaine classification. Preoperative arterial Doppler ultrasonography and arteriography were performed in all patients. The ankle-brachial index (ABI) was calculated preoperatively and postoperatively in all of the cases. Twenty-three patients underwent distal bypass operation. Other 26 patients were followed with medical therapy. The outflow distal anastomoses were performed on posterior tibial, dorsal pedal, anterior tibial, peroneal, and lateral plantar arteries. All patients were followed-up for 3 years and clinical outcomes were recorded. The statistical analyses were performed using unpaired t, Mann Whitney and Wilcoxon tests. RESULTS: There were 3 early and 2 late graft failures. Limb salvage rates were 84.2%, 84.2%, 73.7% in the surgical group, and 82.8%, 69.9%, 64.3% in the medical group respectively in 6 months, 1 year, and 3 years. According to statistical analysis; the levels of the amputations tend to be lower in the surgical group than in the medical group but it was not significant statistically. Surgical treatment reduced the amputation ratio (p<0.05) but medical therapy did not (p>0.05). The difference between preoperative mean ABI [0.26+/-0.06] and postoperative mean ABI [0.80+/-0.24] was significant (p<0.05). CONCLUSION: We think that limb-salvage bypass operation may be preferred for patients with critical limb ischemia and poor distal flow on angiography. Infrapopliteal bypass will provide limb salvage and a functional extremity.