Hypoxia-inducible factors in arteriovenous fistula maturation: A prospective cohort study.

BACKGROUND: Neointimal hyperplasia is the main cause of arteriovenous fistula (AVF) failure. Hypoxia-inducible factors (HIFs) factors are associated with neointimal hyperplasia. Thus, we investigated the association between HIF-2 alpha (HIF-2α) and AVF maturation in end-stage kidney disease (ESKD) patients. METHODS: This prospective cohort study was conducted in 21 voluntary healthy subjects and 50 patients with ESKD who were eligible for AVF creation. Inclusion criteria were being ESKD patients without a history of AVF surgery and dialysis. Eight patients excluded from the study due to having unavailable veins six patients were excluded due to acute thrombosis after surgery. One patient lost to follow-up. A total of 35 patients were included in final analysis. The blood samples were collected a day before the AVF surgery for biochemical parameters and HIF-2α measurement. HIF-2α levels were measured by the ELISA method. RESULTS: Compared with healthy subjects, ESKD patients had a significantly higher level of HIF-2α. [1.3 (1.0-1.9) vs 2.2 (1.6-3.0)] (P = .002). Patients were divided into two groups after the evaluation of AVF maturation, as the mature group (n = 19) and the failure group (n = 16). Serum HIF-2α level was 1.7 (1.1-1.8) in the mature group; however, it was 3.1 (2.8-3.3 in failure group (P < .001). Multiple logistic regression analyses showed that HIF-2α independently predicted AVF maturation. The ROC curve analysis showed that HIF-2α > 2.65 predicted AVF maturation failure with the 87% sensitivity and 94% specificity [AUC:0.947, 95% CI (0.815-0.994), P < .001]. CONCLUSIONS: HIF-2-α levels were higher in ESKD patients than healthy subjects. HIF-2-α could be a marker of AVF maturation failure.

Does arterio-venous fistula creation affects development of pulmonary hypertension in hemodialysis patients?

BACKGROUND: Pulmonary arterial hypertension (PAH) is a common complication in hemodialysis (HD) patients and its pathogenesis is not explained clearly. Arterio-venous fistulas (AVFs) creation may contribute to the development of PAH because of increased pulmonary artery blood flow. However, it was not prospectively evaluated that effect of AVF on the development of PAH. AIM: We aimed to evaluate the effects of AVF on PAH and the relationship between blood flow rate of AVF and pulmonary artery pressure (PAP) in HD patients. PATIENTS AND METHOD: The prospective study included 50 patients with end-stage renal disease. Before an AVF was surgically created for hemodialysis, the patients were evaluated by echocardiography. Then, an AVF was surgically created in the patients. After mean 76.14 ± 11.37 days, the second evaluation was performed by echocardiography. RESULTS: Before AVF creation, 17 (34%) out of 50 patients had PAH. The systolic PAP was significantly higher in the patients with PAH compared with patients without PAH (47.82 ± 9.82 mmHg vs. 30.15 ± 5.70 mmHg, respectively, p = 0.001). In the second evaluation, 19 (38%) out of 50 patients had PAH. The systolic PAP values were significantly higher in the patients with PAH compared with patients without PAH (47.63 ± 8.92 mmHg vs. 25.03 ± 7.69 mmHg, P = 0.001, respectively). There was no relationship between the blood flow rate of AVF and PAP. CONCLUSION: PAH is a common problem in HD patients. AVF has no significant effect on the development of PAH within a short period. Similarly, blood flow rate of AVF also did not affect remarkably the systolic PAP.

Transient cortical blindness and successful recovery after coronary bypass surgery.

Left ventricular injury has a bad prognosis, especially when a coronary artery is involved. After perforation of the left cardiac ventricle by a knife, a 19-year-old male patient presented with: (i) complete bilateral visual loss; (ii) left anterior descending (LAD) artery injury; (iii) severe systemic hypotension. Under emergency conditions and cardiopulmonary bypass, the LAD artery was revascularized by a saphenous vein graft. Bilateral blindness recovered within several days. Cerebral hypoxia as a result of severe systemic hypotension was the most likely underlying mechanism.

The deletion polymorphism of the angiotensin-converting enzyme gene is associated with acute aortic dissection.

Aortic dissection (AD) is a disease characterized by tear of the aortic intimal layer and separation of the arterial wall. Some risk factor such as hypertension and Marfan syndrome is well known in AD. However, the role of genetic factors in AD is largely unknown. Insertion/deletion (I/D) polymorphism of the angiotensin-converting enzyme (ACE) gene is associated with cardiovascular diseases; patients with D allele have higher serum and tissue ACE levels. We investigated the relationship between the I/D polymorphism of the ACE gene and non-syndromic acute AD. Sixteen patients diagnosed with AD were included in the study (mean age: 60.1 +/- 6.2 years). The diagnosis was established by clinical evaluation and imaging techniques. The control group consisted of 22 age-matched patients without AD (60.9 +/- 7.3 years), who suffered from chest pain. Incidence of hypertension was similar in dissection and control groups (62% vs. 59%). The I/D polymorphism was investigated in both groups by PCR analysis. Dissection types according to the DeBakey classification were identified as type 1 (proximal + distal) in 7 patients (43%), type 2 (proximal) in 5 patients (31%), and type 3 (distal) in 4 patients (25%). The D/D and D/I polymorphisms are present in 13 and 3 AD patients, respectively. None of patients with AD have the II polymorphism. The frequencies of the D allele (DD + ID) are significantly higher in dissection group than control (100% vs. 68%, P < 0001). These results indicate that the D allele of ACE gene is a risk factor for AD.

Surgical approach to the management of cardiovascular echinococcosis.

OBJECTIVE: Echinococcosis is a serious health problem in some regions of the world. Although cardiovascular hydatid cyst is rare, its early diagnosis and surgical management is important. METHODS: We reviewed 10 patients with cardiovascular hydatid cyst who underwent surgery in our department between January 1982 and 2007. Standard cardiopulmonary bypass and antegrade cardioplegia with aortic cross-clamping were used in all but one patient. After the cysts were removed, the cavity was cleaned and then obliterated with purse-string sutures. Albendazole was used in all patients. The mean follow-up was 4.5 years. RESULTS: The mean age was 27 years (range 12 to 76 years). Eight patients were men. The hydatid cysts were located on left ventricle (five patients), left atrium (two patients), right ventricle (three patients), right atrium (one patient), pericardium (one patient), and aorta (one patient). Except for two patients who died, all were discharged without postoperative complications. There was no late cardiac mortality or recurrence. CONCLUSIONS: Cardiac hydatid cyst should be treated surgically without delay. Although its surgical treatment carries a high complication rate, gentle handling of the heart during cardiopulmonary bypass minimizes operative risk.

Prevalence of thromboembolic disease including superior vena cava and brachiocephalic veins.

Thrombosis of the brachiocephalic veins or superior vena cava (SVC) is rare. This study was conducted to determine the prevalence and characteristics of thrombosis of brachiocephalic veins and SVC , and its association with symptomatic pulmonary embolism (PE). The prevalence of thrombosis involving the brachiocephalic veins and SVC was evaluated retrospectively at a university hospital during the 3-year period. Patients were identified by hospital records and review of computer-generated lists of of all venograms, contrast-enhanced chest computed tomography, and magnetic resonance angiograms of the upper extremity and SVC. Thrombosis of the brachiocephalic veins and SVC was diagnosed in 33 (0.03 %) of 100,942 patients of all ages [(32 of 70,751 adult patients >or= 20 years; 0.04%)]. Twenty-three (70%) patients initially had secondary thrombosis with multiple risk factors: associated with malignancy in 14 (42%) patients, chronic disorders in 13 (39%) patients, central venous lines (CVL) and peripheral venous lines (PVL) in 9 (27%) patients, and thrombophilia in 10 (38%) of 26 patients. Swelling of the arm, head, and neck was present in 32 (97%) patients. Symptomatic PE developed before thrombosis being treated in 12 (36%) patients. All patients except eight (three, thrombolytic; five, thrombectomy) received anticoagulant therapy. Thrombosis of the SVC and brachiocephalic veins is an uncommon but serious complication in patients with malignancy, chronic disorders, CVL, PVL, and thrombophilia. Because it is important clinical problem with frequent PE, the patients with appropriate clinical findings should be diagnosed early with imaging tests and treated with anticoagulant drugs.

Double-chambered right ventricle mimicking asymmetric septal hypertrophy.

Double-chambered right ventricle (DCRV) is an uncommon congenital heart disease. Anomalous muscle bundles in the right ventricle divide the right ventricle into two portions and cause intracavitary obstruction of the right ventricle. We report a patient with DCRV mimicking asymmetric septal hypertrophy. We did clinical, echocardiographic and angiographic evaluation. Surgical intervention was successfully managed.

A fibromatosis case mimicking abdominal aorta aneurysm.

Retroperitoneal fibrosis is a rare fibrosing reactive process that may be confused with mesenteric fibromatosis. Abdominal aorta aneurysm is rare too and mostly develops secondary to Behcet's disease, trauma, and infection or connective tissue diseases. Incidence of aneurysms occurring as a result of atherosclerotic changes increases in postmenopausal period. Diagnosis can be established with arteriography, tomography, or magnetic resonance imaging associated with clinical findings. Tumors and cysts should be considered in differential diagnosis. Abdominal ultrasound and contrast-enhanced computerized tomography revealed an infrarenal abdominal aorta aneurysm in a 41-year-old woman, but, on surgery, retroperitoneal fibrosis surrounding the aorta was detected. We present this interesting case because retroperitoneal fibrosis encircling the abdominal aorta can mimic abdominal aorta aneurysm radiologically.

Aortic and coronary artery dissection during percutaneous coronary intervention: a case report and review article.

Coronary artery dissection is an uncommon but potentially serious complication in percutaneous coronary interventions. We treated a 53-year-old female patient with right coronary spasm, which was misdiagnosed as a coronary lesion. The coronary spasm resolved with nitrate administration, but proximal coronary dissection developed during angiography. It progressed anterograde and led to inferior myocardial infarction and severe hemodynamic instability due to right coronary artery occlusion. Percutaneous intervention failed, and it was determined that coronary dissection progressed retrograde, across the truncus of the aorta. Ascending aortic grafting and coronary bypass surgery were performed. The patient recovered and was discharged after 10 days. Close cardiothoracic observation is mandatory in patient evaluation and management.

Popliteal artery branching patterns detected by digital subtraction angiography.

PURPOSE: To describe the popliteal and distal branching patterns detected by digital subtraction angiography. MATERIALS AND METHODS: The popliteal branching patterns were analyzed in 535 extremities (270 right, 265 left). Of these, 226 limbs were evaluated bilaterally, while 83 were evaluated unilaterally. The branching patterns were classified according to the level of branching and the presence of hypoplasia or aplasia of the distal branches. RESULTS: Four hundred and seventy-two (88.1%) limbs had a normal level of popliteal artery branching. Type IA was the most frequently encountered pattern. High division of the popliteal artery was seen in 30 (5.6%) limbs. Type IIA was the most frequently encountered pattern among these limbs. Type IIC was not seen. We encountered a new pattern characterized by high division of the peroneal artery with a trifurcation pattern and an anterior tibial artery with a proximal medial course and a distal lateral course. We called this pattern Type IID. Thirty-three (6.1%) limbs exhibited hypoplasia/aplasia of the distal branches. Type IIIA was the most frequently encountered pattern among these limbs. CONCLUSION: Variations that occur in nearly 10% of patients should be understood because they may affect the choice of management strategy.

Surgical approach to the management of Brucella endocarditis.

OBJECTIVE: Brucella endocarditis is a rare complication of Brucella infection; however, it is the major cause of deaths in those infected with this disease. In this study, we aim to discuss the results of seven cases who underwent surgery for Brucella endocarditis in our clinic using the knowledge gathered through the literature. METHODS: We reviewed seven patients with Brucella endocarditis, who underwent surgery in our department between October 1990 and April 2007. Brucella endocarditis was diagnosed by physical examination, laboratory findings, serological tests, blood culture, transthoracic and trans-oesophageal echocardiography. All cases underwent surgery after 4-6 weeks of medical therapy. Antimicrobial treatment was maintained for an average of 6 months after surgery. The mean follow-up was 27.4 months. RESULTS: The mean age was 30 years (range, 5-47 years). Four of the patients were male. Of the cases, aortic valve replacement (AVR) was performed in three, mitral valve replacement (MVR) was performed in three and combined aortic and mitral valve replacement (AVR+MVR) was performed in one patient. Pericardial tube drainage was done in one patient because of pericardial effusion and cardiac tamponade that developed 13 days after surgery. One (14.3%) of our patients died 15 days after surgery. The others were discharged. CONCLUSIONS: We concluded that medical and surgical treatment had to be performed simultaneously for the successful management of Brucella endocarditis, a fatal complication of Brucella infection.

The long-term effects of arteriovenous fistula creation on the development of pulmonary hypertension in hemodialysis patients.

The aim of this prospective study was to evaluate long-term effects of arteriovenous fistula (AVF) on the development of pulmonary arterial hypertension (PAH) and the relationship between blood flow rate of AVF and pulmonary artery pressure (PAP) in the patients with end-stage renal disease (ESRD). This prospective study was performed in 20 patients with ESRD. Before an AVF was surgically created for hemodialysis, the patients were evaluated by echocardiography. Then, an AVF was surgically created in all patients. After mean 23.50 ± 2.25 months, the second evaluation was performed by echocardiography. Also, the blood flow rate of AVF was measured at the second echocardiographic evaluation. Pulmonary arterial hypertension was defined as a systolic PAP above 35 mmHg at rest. Mean age of 20 patients with ESRD was 55.05 ± 13.64 years; 11 of 20 patients were males. Pulmonary arterial hypertension was detected in 6 (30%) patients before AVF creation and in 4 (20%) patients after AVF creation. Systolic PAP value was meaningfully lower after AVF creation than before AVF creation (29.95 ± 10.26 mmHg vs. 35.35 ± 7.86 mmHg, respectively, P: 0.047). However, there was no significant difference between 2 time periods in terms of presence of PAH (P>0.05). Pulmonary artery pressure did not correlate with blood flow rate of AVF and duration after AVF creation (P>0.05). In hemodialysis patients, a surgically created AVF has no significant effect on the development of PAH within a long-term period. Similarly, blood flow rate of AVF also did not affect remarkably systolic PAP within the long-term period.

Isolated penetrating gluteal injuries.

In the authors' institution, 27 patients with gluteal injuries were treated surgically during the past 17 years. All patients were males, and the mean age was 32.4 years. Most patients (89%) had stab wounds. The lesion was on the right buttock in 16 (59%) patients and on the left buttock in 11 (41%) patients. Bleeding was the most common presenting sign. The superior gluteal artery and its branches were the most commonly injured arteries (89%). Surgical procedure was arterial ligation alone in all but one case, whereas one patient underwent coil embolization. Mortality was 11% and included 1 death on arrival to the medical center and 2 intraoperative deaths. To achieve a low rate of morbidity and mortality with such injuries, careful physical examination and immediate surgical or endovascular treatment is needed.

Mobile biatrial thrombus in a patient with mitral stenosis under heparin infusion.

A 58-year-old female patient with complaints of sudden presenting pain and pallor on her left foot was referred to our clinic for urgent embolectomy. On her cardiovascular examination there was an apical grade 2/6 systolic murmur and a grade 2/4 diastolic murmur. The presenting electrocardiography revealed atrial fibrillation with rapid ventricular response. She underwent emergent femoro-popliteal embolectomy. Transthoracic echocardiography showed a mobile 1.4 x 1.7-cm sized left atrial thrombus, mild mitral regurgitation and 9 mmHg mean gradient on mitral valve after embolectomy. Unfractioned (UF) heparin infusion was initiated immediately after surgery. After three days, the control transthoracic echocardiography revealed left atrial thrombus and also a large 'snake-like' thrombus waving in right atrium. The patient underwent biatrial thrombectomy and mitral valve replacement. When she became haemodynamically stable, a bilateral lower limb venous Doppler ultrasonographic study was performed. This study indicated a thrombus formation in the deep veins of the left leg. The origin of the right atrial thrombus was probably a snapped piece of thrombus from the calf deep-veins after the initiation of intravenous UF heparin. In summary, we have reported an extremely rare case of biatrial thrombus in a patient under UF heparin infusion.

Conservative management of the perforation of a side branch of the left main coronary artery during coronary angiography.

We report perforation of a side branch of left main coronary artery during coronary angiography. We suppose that the engaging of the catheter into a small side branch caused this complication. Furthermore, we observed that the conservative approach might be successful in the restoration of such coronary artery perforations. To the best of our knowledge this is the first reported case of left main side branch coronary artery perforation during angiography.