Is it necessary to use an intraluminal shunt in symptomatic patients with contralateral carotid artery stenosis?

BACKGROUND: We aimed to investigate our results of carotid endarterectomy operations in symptomatic patients operated by using an intraluminal shunt and without use of an intraluminal shunt in patients with contralateral carotid artery stenosis. METHODS: We reviewed the results of 144 carotid endarterectomy operations in patients with contralateral carotid artery stenosis from January 2007 to December 2012. These patients were allocated in 2 groups. Group 1 (n = 70) consisted of the patients operated by using an intraluminal shunt and Group 2 (n = 74) consisted of the patients operated without use of an intraluminal shunt. Postoperative neurologic complications were recorded. RESULTS: Temporary neurologic impairment developed in 3 (4.3%) patients postoperatively in group 1 and in 2 (2.7%) patients postoperatively in group 2. This difference was not statistically significant between groups (p = 0.675). None of the patients returned to operation theatre due to excessive bleeding postoperatively. The stroke/death rate was 0.7% in the study group. CONCLUSIONS: We conclude that carotid endarterectomy in symptomatic patients with contralateral occlusion can be performed safely without the systematic use of a shunt. However, it is not possible to define exact indications for use of a shunt as we have no information on the reason why some surgeons used a shunt.

Comparison between normothermic and mild hypothermic cardiopulmonary bypass in myocardial revascularization of patients with left ventricular dysfunction.

AIMS: The aim of this study was to investigate whether normothermic bypass is superior to mild hypothermia in patients with poor left ventricular function. This was achieved by studying defibrillation rates, postoperative requirements of cardiac pacing or other morbidity issues and mortality in patients with left ventricular dysfunction operated upon for elective coronary revascularization. METHODS: Data were collected retrospectively from 252 consecutive patients with left ventricular dysfunction (ejection fraction ≤35%) undergoing coronary revascularization between January 2005 and January 2011. Patients operated upon under mild hypothermia (32 ºC) were placed in Group 1 and under normothermia (≥35 ºC) were placed in Group 2. Comorbidities and postoperative complications were recorded. RESULTS: There were 128 patients in Group 1 and 124 patients in Group 2. Plasma concentrations of CK-MB and troponin T peaked at 6 hours postoperatively, with no significant difference between the groups. Despite longer aortic cross-clamp time and total bypass time in Group 2, significantly less defibrillation requirement rates after aortic declamping was observed. Hospital mortality occured in 16 patients; 8 patients in each group. CONCLUSIONS: Normothermia enables less requirement for defibrillation after aortic declamping and postoperative cardiac pacing in patients with left ventricular dysfunction, which may be interpreted as better myocardial protection under normothermic bypass. However, maintaining normothermia had no effect on postoperative stroke, postoperative atrial fibrillation, renal failure development and mortality.

Histopathological comparison of vascular wall damage created by external cross-clamp and endoluminal balloon occlusion techniques.

AIM: Almost all cross-clamps utilized in vascular surgery, even atraumatic clamps, have been shown to cause mechanical damage to the vascular wall. In recent years, surgical procedures using an endoluminal balloon technique have been reported as an alternative occlusion strategy. This study discusses the histopathological characteristics and comparison between vascular wall damage secondary to the two occlusion techniques in the early postoperative period. METHODS: Twelve adult rabbits were divided into two experimental groups: the clamp group (N. = 6) and the balloon group (N. = 6). External cross-clamp occlusion was applied to the abdominal aorta for 30 minutes via laparotomy in the clamp group. In the balloon group, occlusion was applied for 30 minutes by inflating the catheter balloon, which was inserted through the iliac artery and advanced into the abdominal aorta. The appropriate aortic segments were subsequently extracted in both groups and tissue samples were examined by light and electron microscopy. Finally, the samples were scored for grade of tissue damage. RESULTS: In both experimental groups, tissue damage was apparent. In the investigations carried out under light microscopy, it was observed that the damage caused by balloon occlusion was remarkably less than the damage caused by the cross-clamp technique. In the balloon group, eight tissue samples (66.7%) had grade 1 damage. On the other hand, five tissue samples had grade 3 damage, all of which were in the clamp group. Investigation by electron microscopy revealed that greater intimal, medial, and adventitial damage occurred in the vascular walls of the clamp group samples, and this also corresponded with an increase in immune response and intraluminal thrombosis. CONCLUSION: External clamp and internal balloon occlusion techniques applied to the aorta were compared, and widespread intimal and medial damage were observed in both techniques. However, endoluminal occlusion of the aorta should be the technique of choice in properly selected cases, since it results in lower damage grades, and it should also be used if application of an external clamp is technically difficult.

The role of inflammation in atrial fibrillation following open heart surgery.

This study investigated the role of systemic inflammation in the development of atrial fibrillation (AF) after coronary artery bypass grafting (CABG). CABG was performed using cardiopulmonary bypass in 77 patients. Pre-operative AF was present in six patients (7.8%) and postoperative AF developed in 13 (18.3%) of the 71 patients with pre-operative sinus rhythm. Post-operative mediastinal drainage was significantly increased in patients with post-operative AF compared with those with sinus rhythm. Plasma E-selectin, P-selectin and vascular cell adhesion molecule levels were not significantly different between patients with pre- and post-operative sinus rhythm, those with pre-operative sinus rhythm and post-operative AF, and those with pre- and post-operative AF. There were significant differences between pre- and post-operative C-reactive protein, interleukin (IL)-6 and IL-10 levels within all three groups, but no differences in these parameters between the groups. Thus, in all groups there were significant alterations in mediators indicative of systemic inflammation following CABG, but comparisons between the groups revealed no differences predictive of AF.

Late manifestation of a pseudoaneurysm in the descending thoracic aorta.

Rupture of the descending aorta following deceleration trauma is a catastrophic event because it has a high mortality. Prompt surgical treatment is generally considered to be mandatory. However, a few injured patients may leave the hospital with an undiagnosed aortic rupture which may give rise to a chronic pseudoaneurysm. In this report, a 28-year-old man is presented in whom a pseudoaneurysm of the descending thoracic aortic was diagnosed six months after a car accident.

Coronary artery bypass graft surgery in patients with left ventricular dysfunction.

AIM: The aim of this study was to investigate effects of congestive heart failure on coronary revascularization results in patients with left ventricular dysfunction and operated for elective coronary revascularization. METHODS: The data were collected retrospectively from 126 consecutive patients with left ventricular dysfunction caused by coronary artery disease between January 2007 and January 2012. Patients admitted to hospital with angina complaints without congestive heart failure symptoms were group 1 and patients with severe congestive heart failure symptoms were group 2. Accompanying diseases, postoperative complications and mortality were recorded. RESULTS: There were 66 patients in group 1 and 60 patients in group 2. Postoperative maximal inotropic support was necessary in 24 (36.4%) patients in group 1 for a mean duration of 1.6±0.9 days and in 34 (56.7%) patients in group 2 for a mean duration of 2.9±0.7 days. The proportion of patients with postoperative stay at the intensive care unit longer than 48 hours was significantly higher in group 2 compared to group 1. (p=0.0001) Hospital mortality was significantly higher in group 2 compared to group 1. (p=0.0001) CONCLUSION: Congestive heart failure aggravates the outcome after coronary artery bypass surgery in patients with left ventricular dysfunction.

Thoracic left kidney: a differential diagnostic dilemma for thoracic surgeons.

We report a case of left thoracic kidney that was identified after a detailed workup for a left thoracic mass that appeared on a routine chest roentgenogram of a young adult. Intravenous pyelography and angiography clearly identified this rare anomaly. Anatomical features and clinical implications of this condition are presented.

Physicians' antibiotic prescribing habits for upper respiratory tract infections in Turkey.

The aim of this study was to evaluate the antibiotic prescription rates for upper respiratory tract infections (uRTIs) by primary care physicians in Samsun, Turkey. Data were obtained from the records of 2,083 visits to 8 primary care areas. Trained research students were stationed on site at each of the 8 primary care areas during the study period. Clinical features of patients were documented on a standardized form. Patients who had acute pharyngitis, acute sinusitis, acute otitis media (AOM) and common cold were included in the study. This survey was conducted between June 1, 1999 and July 1, 1999. A total of 2,083 office visits were recorded and 502 (24.1%) of the patients had uRTIs. Physicians approached these conditions empirically, with only 2.9% of patients having a diagnostic test at initial examination. Antibiotics were prescribed for 461 patients (91.8%) with uRTIs (common cold: 41.9%, acute pharyngitis: 94.7%, acute sinusitis: 94.1% and AOM: 100%). 11.5% of the antibiotic prescriptions were inconsistent with current recommendations derived from the literature. Inadequate antibiotic prescribing was documented in 29.7% of antibiotic prescriptions. Errors were frequent in relation to dosage, dosage interval and duration of therapy. Overuse of antibiotics is widespread in our geographic area. Both administrative and educational intervention should be implemented to improve antibotic prescribing habits at the primary health care level to reduce the unnecessary use of antimicrobial agents.

False aneurysm of perforating branch of the profunda femoris artery after external fixation for a complicated femur fracture.

False aneurysm of the profunda femoris artery rarely occurs and is a serious complication following femur fracture. A 39-year-old man who developed a false aneurysm arising from the perforating branch of the profunda femoris artery following an external fixation for a complicated femur fracture was presented. Clinical diagnosis was confirmed by selective arterial angiography after occurrence of significant hemorrhage and swelling of the injured thigh. The false aneurysm was treated by ligation of the perforating branch of the profunda femoris artery and excision of the aneurysmal sac via the medial approach. Clinical status of the patient was uneventful postoperatively. The right thigh swelling decreased rapidly following the operation in 1 week. The patient was discharged on the 10th postoperative day with external fixation. False aneurysm in a branch of the profunda femoris artery is a very rare status following application of the external fixator due to complicated femur fracture. Related literatures and interventions were reviewed on the basis of this case.

Bilateral retrosternal dislocation and hypertrophy of medial clavicular heads with compression to brachiocephalic vein.

A 36-year-old woman with effort dyspnea for 2 years, venous congestion of the left arm for 6 months and who did not have a history of a thoracic trauma was hospitalized. Posterior bilateral dislocation of the sternoclavicular joints and compression of the brachiocephalic vein were diagnosed and conformed by computed tomography (CT). The joint could not be reduced because of the old dislocation and destruction of the joint in the operation. The heads of the clavicles were resected and the vein compression was eliminated. Six weeks later, venous congestion disappeared and the brachiocephalic vein was patent.

The importance of pulmonary artery circulation during cardiopulmonary bypass.

This study sought to determine changes in transpulmonary difference in blood cells and alveolar-arterial oxygen (A-aO2) gradient when pulmonary artery circulation was obstructed in patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). Eighteen patients were divided into group A (control group; X-clamp placed on aorta, n = 9) and group B (pulmonary ischaemia group; X-clamp placed on aorta and pulmonary artery, n = 9). Haematological parameters were compared before CPB and up to 90 min after declamping. A-aO2 gradient differences were compared before and 2 h and 6 h after declamping. A transpulmonary increase in leucocyte levels normalized after 60 min in group A but remained higher in group B. A transpulmonary increase in neutrophils normalized after 60 min in group A and 90 min in group B. Increased lymphocyte levels normalized after 30 min in group A and 90 min in group B. A-aO2 gradient was determined as: group A (294.8 +/- 74.3) and group B (321.2 +/- 73.3) before X-clamping; group A (132.7 +/- 22.7) and group B (236.6 +/- 41.5) 2 h after declamping; and group A (72.2 +/- 22.7) and group B (189.4 +/- 88.9) 6 h after declamping. When pulmonary artery circulation was obstructed during the X-clamping period, leucocyte, neutrophil and lymphocyte sequestration within both lungs increased, and an increased A-aO2 gradient was observed because of tissue damage. To prevent post-operative complications, precautions to maintain normal pulmonary artery circulation are recommended.

The effects of cardiopulmonary bypass on androgen hormones in coronary artery bypass surgery.

The effects of testosterone on coronary vasomotor regulation have been described by several recent reports. Here we investigated changes in serum androgen levels during and after cardiopulmonary bypass (CPB) in patients who had undergone coronary artery bypass surgery. Serum luteinizing hormone, free testosterone and dihydroepiandrestenedione sulphate (DHEA sulphate) levels were evaluated in 38 male coronary artery bypass surgery patients using a chemical immunoassay technique. All hormone levels were corrected to account for haemodilution. Serum-free testosterone level decreased significantly during weaning from CPB (from 15.7 +/- 4.2 nmol/l to 6.2 +/- 2.8 nmol/l), and an even greater decrease was observed in the first post-operative day (5.4 +/- 3.1 nmol/l). On the seventh post-operative day, free testosterone levels reached a normal value (11.8 +/- 5.5 nmol/l), although they were still significantly lower compared with the pre-operative value. There were slight alterations in serum DHEA sulphate levels, although the only significant decrease occurred from the first to the seventh day post-operation (from 4.7 +/- 2.2 mumol/l to 3.7 +/- 1.8 mumol/l, respectively). Serum luteinizing hormone levels were decreased during weaning from CPB (from 4.8 +/- 2.1 mIU/ml to 3.9 +/- 1.8 mIU/ml), but increased rapidly to the pre-operative value (5.5 +/- 2.5 mIU/ml) at the first post-operative day. These results show that CPB affects serum luteinizing hormone, free testosterone and dihydroepiandrestenedione sulphate levels. The free testosterone level decreases significantly both during and after CPB surgery.

Surgical management of iatrogenic femoral artery pseudoaneurysms: A 10-year experience.

BACKGROUND: Vascular complications of cardiac catheterization have increased in line with increasing number of percutaneous interventions. Open repair is the standard method of treatment for true and false aneurysms of femoral artery. We report results of patients operated due to femoral artery pseudoaneurysm after cardiac catheterization. METHODS: Data from 12,261 patients who underwent percutaneous intervention for cardiac catheterization between January 2003 and January 2013 were evaluated. Diagnosis of pseudoaneurysm was established mainly by doppler ultrasonography in patients with complaints of pain and hematoma at the intervention site. Pseudoaneurysms less than 2 cm in diameter were treated non-operatively and were followed up by regular ultrasonographic examination at the outpatient clinic. Pseudoaneurysms with a diameter of 2 cm or more underwent primary repair. All patients were followed up for one year. RESULTS: We detected 55 (0.44%) patients with femoral artery pseudoaneurysm and 42 of them were operated. The mean age was 60.7 ± 6.3 years. Thirty nine (94.5%) patients underwent elective surgery, three (5.5%) patients were operated on under emergency conditions. Operation was performed under local anesthesia in 32 patients, under local anesthesia and sedation in eight patients, and under general anesthesia in three patients. Location of the pseudoaneurysm was the superficial femoral artery in 29 (69%), the common femoral artery in nine (21.4%), and the deep femoral artery in four (9.6%) patients. No limb loss occurred, no patient died and no recurrence was detected during the follow up. CONCLUSIONS: Performing vascular reconstruction before the rupture of pseudoaneurysm is important in terms of morbidity and mortality. We concluded that surgical repair in pseudoaneurysms larger than 20 mm is safe and essential.

Brachial plexus injury during open heart surgery--controlled prospective study.

BACKGROUND: Postoperative brachial plexus injury is often reported because the brachial plexus is stretched by sternotomy and the use of sternal retractors during open heart surgery. In many studies, brachial plexus injuries have been demonstrated by postoperative electrophysiological studies in susceptible patients. In this study, we estimated the incidence, severity, and type of brachial plexus injuries by routine preoperative and postoperative electrophysiological studies of patients undergoing open heart surgery. METHODS: Patients undergoing coronary artery bypass grafting (CABG) surgery (Group 1), heart valve surgery (Group 2), or peripheral vascular surgery (Group 3) were included in the investigation. Electrophysiological studies of both upper extremities were performed five days before and three weeks after the operation. RESULTS: Peripheral nerve problems were found preoperatively in 23 of the 112 patients (21 %). These problems persisted, but similar findings were obtained postoperatively from the left upper extremities of six of the 42 CABG (14 %) and two of the 24 heart valve (8 %) patients who had had normal preoperative evaluations. The patients with injured nerves were older and had undergone longer operation times. There were no differences between the patients with injured nerves and the others with respect to mammary artery harvesting or other operative variables. CONCLUSIONS: There are no reports in the literature of routine preoperative and postoperative electrophysiological studies in large patient groups to evaluate brachial plexus injury during open heart surgery. It is known that heart surgery sometimes causes partial brachial plexus injury, especially in the lower trunk. However, these peripheral nerve problems are usually not considered clinically important and are not investigated. Patients undergoing open heart surgery must be closely followed up for peripheral nerve injury during the postoperative period.

Effect of coronary sinus diastolic balloon pulsation on ischemic myocardium.

OBJECTIVES: To evaluate the effect of coronary sinus diastolic balloon pulsation (CSDBP) on acute myocardial ischemia and infarction. It was hypothesized that this procedure would improve retrograde flow to ischemic areas and allow for more complete oxygen exchange and venous washout of metabolites, with elevated coronary sinus pressure and retrograde pulsation. ANIMALS AND METHODS: This two-part study was done on 10 dogs. First, CSDBP was applied to normal myocardium by a balloon catheter and a pump system at beat to beat cardiac cycles of 1:1, 2:1 and 3:1. Then coronary ischemia was obtained by coronary artery ligation and the procedure was repeated. Electrocardiographic (ECG), arterial and coronary sinus pressure alterations were monitored continuously, and arterial, mixed venous and coronary sinus blood lactate concentrations were measured at each stage of the study. RESULTS: In the first stage no hemodynamic deterioration was observed. In the second stage, mean ECG-ST segment elevation was 6.30+/-0.95 mm (P<0.01) and coronary sinus blood lactate concentration increased to 5.37+/-0.37 mmol/L from 1.95+/-0.31 mmol/L (P<0.01). ECG-ST segment elevation decreased to 3.73+/-0.64 mm and coronary sinus blood lactate concentration decreased to 4.79+/-0.28 mmol/L (P<0.05) with 1:1 beat to beat CSDBP. ECG-ST segment elevation decreased to 2.95+/-0.73 mm and coronary sinus blood lactate concentration decreased to 4.4+/-0.22 mmol/L with 2:1 CSDBP. ECG-ST segment elevation decreased to 3.6+/-0.42 mm and coronary sinus blood lactate concentration decreased to 4.17+/-0.22 mmol/L with 3:1 CSDBP as well. DISCUSSION: Results showed that CSDBP technique lowered the increased ECG-ST segment elevation and myocardial lactate production.