An alternative method of transperitoneal graft introduction in aortobifemoral bypass surgery.

INTRODUCTION: Intestinal injury and bleeding, which usually occurs while taking the graft through the transperitoneal tunnel, is one of the most important complications of aortobifemoral bypass surgery. In this study, case reports were examined where, for some reason, the tunneller instrument could not be used to create the transperitoneal tunnel and the tunnelling forceps was used. In some of these cases, the grafts were taken through conventionally and in others an alternative method was used. METHODS: Between 2002 and 2013, the records of 81 patients treated surgically by aortobifemoral bypass for peripheral arterial disease, were investigated retrospectively. In the conventional method, after creating a tunnel with tunnelling forceps, the forceps was re-introduced into the tunnel and the graft was clasped and brought through the tunnel. In the alternative method, a nylon tape was left as a guide in the tunnel while creating the tunnel, and the forceps was not introduced again. The graft was taken through the tunnel with the help of the nylon tape. Patients treated with the conventional method were included in group 1 (n = 49) and patients in which the graft was guided with nylon tape were included in group 2 (n = 32). The groups were compared peri-operatively. RESULTS: There were no significant differences between the groups in terms of co-morbidity factors. Extubation time, intensive care length of stay, revision for bleeding, other postoperative complications, and infection and late-term infection rates were similar in the two groups (p > 0.05). Hospital length of stay and blood usage were significantly higher in group 1 (p < 0.05). Drainage amounts were higher in group 1 but not statistically significant. CONCLUSION: Using nylon tape to introduce the graft into the femoral area during aortobifemoral bypass operations was found to be more effective than using the tunnelling forceps.

Emergency surgical approach to device emboli due to migration of the atrial septal defect occluder.

INTRODUCTION: Atrial septal defect (ASD) transcatheter occlusion techniques are now established as the preferred method and have become an alternative to surgery under extracorporeal circulation. In this study, we aimed to present our emergency surgical approach to cases of device embolization due to migration of the atrial septal defect occluder. MATERIAL AND METHODS: Between June 2009 and June 2011, 6 patients underwent emergency operations due to device emboli secondary to migration of the transcatheter atrial septal defect occluder during the early period. Mean age was 25.5 years (15-45) and 3 of the patients were female (50%). The diagnosis was made via transthoracic echocardiography (TTE) preoperatively. RESULTS: All of these 6 patients underwent emergency operations. Mean postoperative intensive care unit (ICU) stay was 2.2 days and mean hospital stay was 6 days. No early or late postoperative mortality was seen. Mean postoperative follow-up time was 19.3 months (range: 5-28 months). Early- and late-period TTE examinations showed no residual interatrial shunting. One patient developed a right atrial thrombus in the postoperative 22(nd) month as a complication of long-term follow-up. He was treated with anticoagulant therapy for 6 months with complete resolution at the TTE. CONCLUSIONS: Transcatheter occlusion of secundum type ASD provides prominent clinical improvement, as well as a regression in dimensions of cardiac chambers. Nevertheless, this technique has drawbacks such as distal migration and residual shunts. Consequently, we think that unfavorable anatomy and device diameter are major issues in device migration. Oversizing also increases the migration risk.

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

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

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

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

Axillary artery transection after shoulder dislocation.

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

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

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

Assessment of protective effects of pheniramine maleate on reperfusion injury in lung after distant organ ischemia: a rat model.

OBJECTIVE: The aim of this study is to investigate the protective effects of methylprednisolone (MP) and pheniramine maleate (PM) on reperfusion injury of lungs developing after ischemia of the left lower extremity of rats. MATERIALS AND METHODS: A total of 28 randomly selected male rats were divided into 4 groups, each consisting of 7 rats. Group 1 was the control group. Group 2 was the sham group (ischemia/reperfusion [I/R]). Rats in group 3 were subjected to I/R and given PM (Ph group) and rats in group 4 were subjected to I/R and given MP (Pn group). RESULTS: Malondialdehyde levels were significantly lower in Ph group than in I/R group (P < .05). Superoxide dismutase and glutathione peroxidase enzyme activities were found to be significantly higher in Ph group than in the I/R group (P < .05). Histological examination demonstrated that PM had protective effects against I/R injury. CONCLUSIONS: The PM has a protective effect against I/R injury in rat lung.

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

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

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.

Comparison of inflow occlusion on the beating heart with cardiopulmonary bypass in the extraction of a mass lesion or a foreign body from the right heart.

OBJECTIVE: Two basic surgical techniques exist in the extraction of a mass lesion or a foreign body from the right atrium and/or the right ventricle. These are inflow occlusion of the right heart and with assistance of the cardiopulmonary bypass (CPB). In this study, these two methods were compared. METHODS: Between May 2001 and April 2010, 15 patients were operated upon for the extraction of a mass lesion or a foreign body from the right heart. Seven patients were operated upon using venous inflow occlusion technique, whereas eight patients were operated upon using CPB. These two groups were evaluated and compared in terms of clinical parameters. RESULTS: Intracardiac masses or foreign bodies were completely removed by using both methods. Patients who were operated upon using inflow occlusion on beating heart (IOBH) developed no postoperative complication, whereas two patients who were operated upon with CPB developed complications, postoperatively. Moreover, duration of hospital stay, duration of intensive care unit (ICU) stay, and intubation time were significantly lower in the IOBH group when compared with the CPB group. In the CPB group, the amount of blood transfused was significantly higher. CONCLUSIONS: In suitable patient groups, the IOBH technique could be safely performed by experienced centers.

Timing of levosimendan in cardiac surgery.

OBJECTIVE: Levosimendan (LS) is a new inodilator agent that improves cardiac contractility by increasing the sensitivity of troponin C to calcium, which usage in cardiac surgery has been growing in the recent years. We aimed to determine the best timing of the administration of LS in high-risk patients who underwent cardiovascular surgery. METHODS: Fifteen patients were evaluated retrospectively who have left ventricular dysfunction, underwent open-heart surgery and were applied LS in different phases of operation. Patients were divided into 3 groups according to timing of LS. Levosimendan infusion (0. 1 microg-1kg-1min) was applied after the induction of anaesthesia (n=5) (Group 1), during the pump removal period (n=5) (Group 2) and in postoperative period (n=5) (Group 3). Demographic data, operative characteristics, mean arterial pressure (MAP), mean pulmonary arterial pressure (MPAP), pulmonary wedge capillary pressure (PWCP), cardiac index (CI), inotropic agent consumption, postoperative urine output, lactate levels of groups were compared between before and after LS treatment. Data were evaluated by Fisher exact, Kruskal-Wallis, Mann-Whitney U and Wilcoxon rank tests. RESULTS: In all patients, urine output was satisfactory 24 hours after LS application. There was a significant increase in CI of all 3 groups (p=0.04). Also, there was a significant decrease in PCWP of all 3 groups before and after LS (p=0.04). There was a significant decrease in MPAP in Group 2 and 3 (p=0.04). Twenty- four hours after LS application, whereas all inotropic agents could be stopped in Group 1 and 2, in Group 3 inotropic infusion (dopamine [10 microg-1kg-1min (5-17.5)], dobutamine [15 microg-1kg-1min (5-20)] and adrenaline [0.4 microg-1kg-1min (0.15-0.65)]) couldn't be stopped (p=0.007). During postoperative period, in Groups 1 and 2 one case from each required intraaortic balloon pump, while in Group 3 four patients were applied intraaortic balloon pump (p=0.08). CONCLUSION: According to our experience, LS is effective in high-risk cases during cardiac surgery, especially during the intra-operative and pump removal periods;however, no successful outcomes were observed during the post-operative period. As a result, case selection and timing should be performed well when using LS.

[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.