Stent Implantation May Fail Sometimes in Coronary Complications: Extension of an Iatrogenic Left Main Coronary Artery Hematoma.

Coronary artery perforations and dissections, associated with cardiac tamponade or acute vessel closure, are life-threatening complications of percutaneous coronary intervention. In some cases, subepicardial hematomas could occur and compress the vessel. A 59-year-old woman was admitted to our hospital with chest pain and was diagnosed with non-ST-elevation myocardial infarction. Coronary angiography showed the total occlusion of the diagonal artery. During the intervention, left main coronary artery dissection and intramural hematoma occurred as coronary complications. The left main coronary artery was stented; however, the extension of the hematoma through the ostium of the left anterior descending artery caused further complications. The patient underwent an urgent coronary artery bypass graft surgery and was discharged on the seventh postoperative day.

Internal Perivenous Compression for venous insufficiency at the Saphenofemoral Junction: Early and Midterm Results and Operative Pain.

OBJECTIVES: To assess the postoperative pain and midterm results of patients undergoing internal perivenous compression with internal compression therapy (ICT) for venous insufficiency at the saphenofemoral junction (SFJ). MATERIALS AND METHODS: Patients managed with ICT between April and October 2019 for grade 4 venous reflux at the SFJ were retrospectively evaluated. The venous clinical severity score (VCSS) was calculated preoperatively and 1, 3, and 6 months postoperatively. Postoperative pain was assessed with the visual analog scale (VAS). Control Doppler ultrasound imaging was performed 6 months postoperatively. RESULTS: Forty-five patients [14 (31%) males and 31 (69%) females; mean age, 47 ± 13 years] were included. The median preoperative VCSS was 7 (5-8.5). The median VCSS at 1, 3, and 6 months postoperatively was 6 (4-7.5), 4 (3-5.5), and 3 (2-4), respectively, and these values were significantly lower than the preoperative score (p = 0,001, p < 0.001, and p < 0.001, respectively). The postoperative VAS score was 0 in 6 patients (13%), 1 in 17 patients (38%), 2 in 6 patients (13%), 3 in 15 patients (33%), and 4 in 1 patient (2%). At 6 months, reflux was absent in 9 (20%), grade 1 in 20 (44%), and grade 2 in 16 (36%) patients. A vena saphena magna diameter of >6.7 mm predicted grade >1 reflux at 6 months [87.5%, with an area under the curve of 0.78 (p < 0.001)]. No complications occurred. CONCLUSION: ICT alleviated symptoms and reduced reflux grade in patients with venous insufficiency at the SFJ. This therapy can be applied with satisfactory patient comfort.

Dynamic Changes in Perioperative Cellular Inflammation and Acute Kidney Injury after Coronary Artery Bypass Grafting.

INTRODUCTION: This study investigated the role of the neutrophil-lymphocyte ratio (NLR), the perioperative changes in NLR (delta-NLR), the platelet-lymphocyte ratio (PLR), and the platelet count in predicting acute kidney injury (AKI) following coronary artery bypass grafting (CABG) during hospital stay. METHODS: The records of 396 patients with preoperative creatinine < 1.5 mg/dl undergoing isolated CABG between October 2015 and October 2019 were reviewed retrospectively. Diagnosis of AKI was based on the Kidney Disease Improving Global Outcomes definition. Demographic data, operative data, in-hospital mortality, preoperative NLR, PLR, and platelet counts were compared between patients with (AKI group) and without (non-AKI group) postoperative AKI. Additionally, NLR, delta-NLR, and PLR values were calculated daily for the first four postoperative days. A "subsequent AKI group" was formed for the first four postoperative days by excluding patients diagnosed with AKI. The daily and overall predictivity of the markers for AKI are investigated. RESULTS: AKI was present in 86 patients during the postoperative period, while 310 patients had normal postoperative renal functions. NLR, delta-NLR, and PLR on the first four postoperative days (P<0.001 for all) were significantly associated with the development of AKI in subsequent days. Multivariate analysis identified postoperative NLR (odds ratio 1.17, 95% confidence interval 1.11-1.23; P<0.001) as an independent predictor of AKI. PLR lost its significant association with AKI at the values measured at discharge from hospital (P>0.05). CONCLUSION: NLR values measured on the first four days postoperatively are a useful tool in predicting AKI during hospital stay following CABG.

Outcomes of Thrombolytic Therapy of Tunnelled Hemodialysis Catheter Dysfunction.

INTRODUCTION: Intraluminal thrombolytic therapy is the first step treatment of thrombotic malfunction of tunneled hemodialysis catheters (THC). The factors that affect catheter restoration and also catheter survival following thrombolytic therapy are not well described. In this study, we aimed to reveal the predictors that affect the success of the procedure and also present post-restoration catheter patency after intraluminal thrombolytic administration. METHOD: This retrospective study included 62 patients with tunneled THC thrombosis treated with alteplase between 2017 and2020 in the study center. Age, comorbidities, the use of antiplatelet and anticoagulants, a history of catheter thrombosis, time on dialysis, the duration of the catheter were investigated as possible predictors of procedural success. The independent predictive factors for procedural success were evaluated by using backward stepwise likelihood ratio logistic regression analysis. Primaryand assisted patencieswere presented with Kaplan-Meier graphs. RESULTS: Thrombolityc was administered to 62 patients 102 times. The median primary patency from the first thrombolytic administration to a second catheter thrombosis was 9 months (range 1-20 months). The overall median patency was 12 months (range 2-23 months). The overall procedural success rate was 79.4% (81/102).Multivariate analyses revealed that a history of prior catheter thrombosis was the only risk factor for procedural success (OR: 0.49; 95% CI: 0.26-0.91; p = 0.004). The need for a second dwell time among patients with prior history of thrombolysis was significantly higher compared to patients without a history of catheter thrombosis (12/26 patients, 46.2% and 6/55 patients, 10.9%; respectively; p = 0.001). CONCLUSION: The success of thrombolysis in subsequent de novo THC thrombosis decreases in patients who previously required intraluminal thrombolytic administration. Identifying patient subgroups with a high risk for THC thrombosis may be useful to investigate effective secondary prevention strategies.

A Pseudocoarctation of the Aorta With a Left Subclavian Artery Aneurysm, A Case Report and A Review of the Literature.

Here we present a 47-year-old male diagnosed with a pseudocoarctation of the aorta and a funnel-like subclavian artery aneurysm with a large orifice and severe aortic valve insufficiency. The patient underwent a two-stage repair for both pathologies. After an aortic valve replacement, postcardiotomy pericardial effusion occurred and was medically managed. Six months later, the patient underwent a distal arcus aorta and subclavian artery replacement with a left posterolateral thoracotomy as the second stage. Due to the strict adhesions, pulmonary veins were not cannulated and an extracorporeal bypass between the pulmonary artery and femoral artery was used for distal body perfusion. The coincidence of subclavian aneurysms and a pseudocoarctation of the aorta is rare and a literature review was performed to identify treatment options for this pathology.

Dynamic Changes in Perioperative Cellular Inflammation and Acute Kidney Injury after Coronary Artery Bypass Grafting

Abstract Introduction: This study investigated the role of the neutrophil-lymphocyte ratio (NLR), the perioperative changes in NLR (delta-NLR), the platelet-lymphocyte ratio (PLR), and the platelet count in predicting acute kidney injury (AKI) following coronary artery bypass grafting (CABG) during hospital stay. Methods: The records of 396 patients with preoperative creatinine < 1.5 mg/dl undergoing isolated CABG between October 2015 and October 2019 were reviewed retrospectively. Diagnosis of AKI was based on the Kidney Disease Improving Global Outcomes definition. Demographic data, operative data, in-hospital mortality, preoperative NLR, PLR, and platelet counts were compared between patients with (AKI group) and without (non-AKI group) postoperative AKI. Additionally, NLR, delta-NLR, and PLR values were calculated daily for the first four postoperative days. A "subsequent AKI group" was formed for the first four postoperative days by excluding patients diagnosed with AKI. The daily and overall predictivity of the markers for AKI are investigated. Results: AKI was present in 86 patients during the postoperative period, while 310 patients had normal postoperative renal functions. NLR, delta-NLR, and PLR on the first four postoperative days (P<0.001 for all) were significantly associated with the development of AKI in subsequent days. Multivariate analysis identified postoperative NLR (odds ratio 1.17, 95% confidence interval 1.11-1.23; P<0.001) as an independent predictor of AKI. PLR lost its significant association with AKI at the values measured at discharge from hospital (P>0.05). Conclusion: NLR values measured on the first four days postoperatively are a useful tool in predicting AKI during hospital stay following CABG.

Coarctation of the aorta with aortic and subclavian artery aneurysms.

Coarctation of the aorta discovered in adulthood is uncommon. The formation of aneurysms from the coarctation segment and in the low-pressure area is even rarer. The surgical management of coarctations can be challenging due to calcifications and concomitant cardiovascular and lung disease. We present a case with coronary artery disease, bilateral bullae, left subclavian artery aneurysm, saccular aortic aneurysms originating proximal to the coarctation and from the coarctation itself, and a remnant of ductus arteriosus. The surgical management and possible histopathologic causes for aneurysm formation are discussed.

On-pump coronary artery bypass with concomitant descending thoracic aorta-bi-iliac bypass: A case report.

The presence of critical coronary artery disease and concomitant critical limb ischemia represents a clinical challenge. Single-stage operations for cardiac and peripheral revascularization can be an option in such cases. The "Süzer technique" provides a more physiological extra-anatomical vascular reconstruction by using the descending thoracic aorta as the inflow source. This is an alternative to the more widely used technique of ascending aorta to bifemoral bypass and concomitant coronary revascularization. We report a case of critical limb ischemia with juxtrarenal aortic occlusion and left main coronary artery stenosis treated with concomitant coronary artery bypass grafting and descending thoracic aorto-bi-iliac bypass using a modification of the Süzer technique.

Comparison of Cilostazol and Naftidrofuryl in an Experimental Acute Ischemia-Reperfusion Model.

INTRODUCTION: Naftidrofuryl and cilostazol are drugs with proven efficacy in the treatment of claudication in peripheral vascular disease. In this experimental study, we evaluated the effects of naftidrofuryl and cilostazol in ischemia-reperfusion (IR) injury on various tissues. MATERIALS AND METHODS: 40 male albino Wistar rats (8-12 weeks old, 250-350 g.) are randomly divided into 4 groups: Control (Group 1), sham (group 2), cilostazol pre-treatment (group 3), naftidrofuryl pre-treatment (group 4). During 21 days placebo is given to group 2, 12 mg/kg/day cilostazol is given to group 3, 50 mg/kg/day naftidrofuryl is given to group 4 orally. Ischemia and reperfusion are induced at the lower hind limb in Groups 2, 3 and 4. Ischemic muscle, kidney, liver, heart, brain and blood samples are obtained. The total antioxidant capacity, oxidant levels and oxidative stress index are studied for each group. RESULTS: Both drugs have protective effects of remote organ injury following IR. Systemic effects are similar to each other, both have protective effects of IR injury. It showed no statistical significance in the total antioxidant capacity. Total oxidant levels are significantly affected by cilostazol in the heart (p < 0.01) and by naftidrofuryl in the liver (p < 0.01). The effect on oxidative stress was only significant with cilostazol on the heart (p < 0.01). CONCLUSION: Cilostazol and naftidrofuryl had beneficial effects in all tissues against tissue damage caused by IR injury. In ischemic muscle, kidney and heart cilostazol had improved outcomes comparing to naftidrofuryl. Naftidrofuryl had benefits over cilostazol in liver tissue.

A Synchronous Ipsilateral True Superficial Femoral Artery and Profunda Femoris Artery Aneurysm With Rupture: A Case Report and Review of the Literature.

Atherosclerotic true aneurysms of the superficial femoral artery (SFA) and profunda femoris artery (PFA) are rare and difficult to detect. The synchronous presence of SFA and PFA aneurysms is even rarer. Herein, we present a case with ipsilateral true SFA and PFA aneurysms diagnosed with rupture. A review of the international literature is made, and the diagnosis and treatment options of this rare condition are discussed. A 75-year-old male was admitted to our hospital with an aneurysm on the distal SFA and the ipsilateral PFA, as well as a hematoma around the PFA. It was difficult to determine the source of the rupture before surgery, even with proper imaging. Successful ligation of the PFA and an aneurysmectomy followed by a bypass grafting for the SFA were performed. An intraoperative examination revealed that the SFA aneurysm had ruptured. In elderly males with a history of ectasia or aneurysm on the aorta or peripheral arteries, a synchronous aneurysm on the SFA or the PFA should be suspected.

Predicting Outcomes of Penetrating Cardiovascular Injuries at a Rural Center by Different Scoring Systems.

OBJECTIVE: To compare the anatomical and physiological scoring systems and the outcomes of surgical management of penetrating cardiovascular trauma at a rural center. METHODS: Seventy-seven patients underwent emergency surgery at our center between January/2012 and October/2018 due to penetrating cardiovascular trauma. Injury Severity Score (ISS), Revised Trauma Score (RTS), New Injury Severity Score (NISS), and Trauma and Injury Severity Score (TRISS) were calculated. The validation of these risk scores to predict mortality was assessed by the area under the receiver operating characteristic curve analysis. RESULTS: All trauma scores were correlated with mortality. As ISS, NISS, and TRISS values increased and RTS values decreased, the mortality rate increased. The area under the curve (AUC) in the receiver operating characteristic curve analysis was 0.943 for TRISS, 0.915 for RTS, 0.890 for ISS, and 0.896 for NISS (P<0.001 for each). Logistic regression analysis revealed that scores were correlated with mortality (P<0.001 for each). By investigating cardiac injuries alone, only TRISS and RTS results correlated with mortality for cardiac injuries (Mann-Whitney U test, P=0.003 and P=0.01, respectively). The AUC was only statistically significant for TRISS and RTS (AUC=0.929, P<0.05 for both). For vascular injuries, all the scores were significantly correlated with in-hospital mortality (Mann-Whitney U test, P<0.001 for each). TRISS had the highest AUC (AUC=0.946, P<0.001). CONCLUSION: TRISS has the highest predictivity for in-hospital mortality in patients with penetrating cardiovascular trauma.

Carotid Doppler ultrasonographic findings of dapagliflozin use in type 2 diabetic patients.

AIM: Sodium-glucose cotransporter 2 inhibitors have been shown to reduce the risk of cardiovascular disease in type 2 diabetes (T2DM) patients. The purpose of this study was to evaluate cardiovascular disease risk indirectly through Doppler ultrasonography (USG) of carotid artery vascular markers in T2DM patients using dapagliflozin. METHODS: One hundred forty-five patients presenting to our clinic between March 2016 and June 2018 and diagnosed with T2DM were included in the study. These were divided into two groups - a dapagliflozin group of 85 patients and a 60-member non-dapagliflozin control group. Common carotid artery end-diastolic velocity (EDV), peak systolic velocity (PSV), and resistive index (RI) parameters were evaluated using Doppler USG in both groups. RESULTS: The mean duration of follow-up was 2.2 ± 0.4 years. Mean ages were 45 ± 14 years in the dapagliflozin group and 42 ± 15 in the control group. Mean HbA1c was 7.4 ± 1.6 in the dapagliflozin group and 7.3 ± 2.1 in the control group. Common carotid artery, PSV, and EDV parameters were higher (p = .012/p = .036), while RI was lower (p ˂ .001), in the dapagliflozin group than in the control group. CONCLUSION: Vascular resistance was lower in the group using dapagliflozin for diabetes management.

Predicting outcomes of penetrating cardiovascular injuries at a rural center by different scoring systems

Abstract Objective: To compare the anatomical and physiological scoring systems and the outcomes of surgical management of penetrating cardiovascular trauma at a rural center. Methods: Seventy-seven patients underwent emergency surgery at our center between January/2012 and October/2018 due to penetrating cardiovascular trauma. Injury Severity Score (ISS), Revised Trauma Score (RTS), New Injury Severity Score (NISS), and Trauma and Injury Severity Score (TRISS) were calculated. The validation of these risk scores to predict mortality was assessed by the area under the receiver operating characteristic curve analysis. Results: All trauma scores were correlated with mortality. As ISS, NISS, and TRISS values increased and RTS values decreased, the mortality rate increased. The area under the curve (AUC) in the receiver operating characteristic curve analysis was 0.943 for TRISS, 0.915 for RTS, 0.890 for ISS, and 0.896 for NISS (P<0.001 for each). Logistic regression analysis revealed that scores were correlated with mortality (P<0.001 for each). By investigating cardiac injuries alone, only TRISS and RTS results correlated with mortality for cardiac injuries (Mann-Whitney U test, P=0.003 and P=0.01, respectively). The AUC was only statistically significant for TRISS and RTS (AUC=0.929, P<0.05 for both). For vascular injuries, all the scores were significantly correlated with in-hospital mortality (Mann-Whitney U test, P<0.001 for each). TRISS had the highest AUC (AUC=0.946, P<0.001). Conclusion: TRISS has the highest predictivity for in-hospital mortality in patients with penetrating cardiovascular trauma.

An evaluation of rivaroxaban and clopidogrel in a rat lower extremity ischemia-reperfusion model: An experimental study.

BACKGROUND: This study aims to compare clopidogrel and rivaroxaban against ischemia-reperfusion injury after a long reperfusion time and to investigate its effects on various tissues. METHODS: A total of 40 Wistar rats were included in the study and were randomly divided into four groups (n=10 per group). Groups were defined as follows: control (Group 1), sham (Group 2), clopidogrel pre-treatment (Group 3), and rivaroxaban pre-treatment (Group 4). Ischemia (6 h) and reperfusion (8 h) were induced at the lower hind limb in Groups 2, 3, and 4. The ischemic muscle, heart, kidney, liver, and plasma tissues of the subjects were obtained to test for the oxidant (malondialdehyde) and antioxidants (glutathione, superoxide dismutase, and nitric oxide). RESULTS: Malondialdehyde levels were significantly higher in the sham group, compared to the controls in all tissues. Clopidogrel and rivaroxaban pre-treatment significantly decreased malondialdehyde levels, compared to the heart, ischemic muscle, liver, and blood tissues of the sham group. Kidney malondialdehyde levels were reduced only by rivaroxaban. Group 4 had significantly decreased malondialdehyde levels, compared to Group 3 in ischemic muscle (p<0.010). The glutathione reduction, compared to sham group, in the kidney was only significant for Group 4 (p<0.050). With clopidogrel and rivaroxaban pretreatment, nitric oxide levels significantly decreased only in the heart tissue, compared to sham group (p<0.001 and p<0.050, respectively). CONCLUSION: The study results suggest that rivaroxaban and clopidogrel are effective in reducing ischemia-reperfusion injury in the heart, ischemic muscle, liver, and blood. Rivaroxaban also protects the kidneys and is superior to clopidogrel in ischemic muscle protection.

The use of rivaroxaban in deep venous thrombosis associated with vena cava inferior agenesis.

Inferior vena cava agenesis is a rare anomaly which may result in deep vein thrombosis. There is no clear scientific evidence for the most effective therapeutic management, optimal duration, or the choice of anticoagulant therapy. Herein, we report an 18-year-old male case with deep vein thrombosis associated with inferior vena cava agenesis who was on rivaroxaban as a lifelong anticoagulation treatment for symptoms of venous stasis and the presence of heterozygotic thrombophilic mutations.

Treatment of Candida sternal infection following cardiac surgery - a review of literature.

BACKGROUND: Candida sternal wound infections (SWIs) following cardiac surgery are rare but are associated with a high mortality rate. Guidelines on this topic either propose no suggestions for management or offer recommendations based on a small number of reports. METHODS: This paper presents a case of a Candida SWI and its successful treatment with debridement using a burr, negative pressure vacuum therapy (NPVT) and dermal grafting. To investigate different methods of treating Candida SWIs following cardiac surgery, a review was completed using the MEDLINE database. Reports without English abstracts and without defined outcomes of therapy for individual patients were excluded. RESULTS: Seventy-seven cases of Candida SWIs following cardiac surgery were identified in 20 articles published since 1999, including our case. Treatment strategies are identified: omentum flap; muscle flap; debridement and secondary wound healing with or without NPVT; debridement and primary closure; incision and drainage; only medical therapy. Patients documented in the articles were classified based on the following outcomes: cured (n = 41 patients [including the present case]), relapse infection (n = 25 patients) and death (n = 11 patients). The various methods used to treat patients were analysed. CONCLUSIONS: Delayed closure reoperation with surgical debridement and NPVT have favourable outcomes. In the presence of widespread osteomyelitis, the use of omental flaps is advocated. Treatment with muscle flaps has a high rate of relapse. Debridement and secondary healing or conservative management with antifungals alone can be considered in the treatment of relapsing infection.

Ruptured Abdominal Aortic Aneurysm with a Suprarenal Tumor.

This paper presents a case study of a patient that underwent surgery for a ruptured abdominal aneurysm. The postoperative course was complicated by resistant hypertension and tachycardia. A suprarenal mass was detected in the computed tomography scan with radiological suspicion of pheochromocytoma. Few cases of pheochromocytoma coexisting with aneurysms have been reported. Management of cardiovascular stability is crucial in such cases. Despite the lack of evidence, pheochromocytomas might have a role in the etiology of aortic aneurysms.

Ruptured abdominal aortic aneurysm with a suprarenal tumor

Abstract This paper presents a case study of a patient that underwent surgery for a ruptured abdominal aneurysm. The postoperative course was complicated by resistant hypertension and tachycardia. A suprarenal mass was detected in the computed tomography scan with radiological suspicion of pheochromocytoma. Few cases of pheochromocytoma coexisting with aneurysms have been reported. Management of cardiovascular stability is crucial in such cases. Despite the lack of evidence, pheochromocytomas might have a role in the etiology of aortic aneurysms.

Aortic valve replacement for papillary fibroelastoma.

Surgery is indicated for symptomatic patients with papillary fibroelastomas (PFE) on the aortic valve. The valve is commonly spared during tumor excision. Rarely, aortic valve replacement (AVR) is needed. We present a case requiring AVR for an aortic valve PFE and review the literature to determine the risk factors for failure of aortic valve-sparing techniques in patients with PFE.

Concomitant Persistent Atelectasis following TEVAR Due to a Descending Aortic Aneurysm: Hybrid Endovascular Repair and ECMO Therapy.

Many thoracic aortic aneurysms are discovered incidentally, and most develop without symptoms. Symptoms are usually due to sudden expansion of the aneurysm, which can cause a vague pain in the back, or sometimes a sharp pain that may denote the presence of impending rupture. Other symptoms are related to pressure on adjacent structures, such as pressure on the bronchus that can cause respiratory distress, or pressure on the laryngeal nerve causing vocal hoarseness. Pressure on the esophagus can cause difficulty in swallowing. Currently, open surgery and thoracic endovascular aneurysm repair (TEVAR) are the choices of treatment for descending thoracic aneurysms (DTA). The decision to intervene on a DTA depends on its size, location, rate of growth and symptoms, and the overall medical condition of the patient. The indications for TEVAR should not differ from those for open surgery and typically include aneurysms larger than 6 cm in diameter. Saccular and symptomatic aneurysms are often repaired at a smaller size. It is also suggested that aneurysms with a growth rate more than 1 cm per year, or 0.5 cm in 6 months should be considered for early repair.Despite the close proximity of the aorta and left main bronchus, atelectasis caused by thoracic aortic aneurysms is rare. We review the case report of a patient with concomitant persistent left pulmonary atelectasis causing acute respiratory distress due to complete compression of the left main bronchus after TEVAR of a descending thoracic aortic aneurysm.