Ultrasound-accelerated catheter-assisted thrombolytic therapy applications in deep vein thrombosis.

BACKGROUND: Ultrasound-accelerated catheter-directed thrombolysis (UCT) increases the invasion of thrombolytic agent into the thrombus using ultrasonic energy, provides less infusion of thrombolytic agent, reduces complication, and post-thrombotic syndrome (PTS) development rates. For these reasons, this procedure is a promising method for the treatment of deep vein thrombosis (DVT). MATERIALS AND METHODS: Patients diagnosed with DVT by ultrasonography (USG) who underwent UCT between May 2013 and August 2014 at Gazi University Hospital Cardiovascular Surgery Clinic were included in the study. The demographic characteristics and postoperative acute and long-term patency rates and deep venous insufficiency rates were evaluated retrospectively to determine the efficacy of the UCT procedure. Patients were classified as acute, subacute, and chronical DVT according to the onset of complaints. The efficacy of the UCT procedure was assessed by Doppler USG performed 6 months and 2 years after the procedure, and patients were re-evaluated for deep venous insufficiency and thrombus findings to determine the relationship between UCT procedure and deep venous insufficiency. RESULTS: In acute phase, 57.1% (n = 8) complete and 35.7% (n = 5) partial openings were obtained. No complete patency was obtained in any of the subacute patients. However, partial openness rate was 60%. In patients admitted during the chronic period, complete patency was obtained in 20% (n = 8) and partial openings in 60% (n = 3). Although thrombolysis success was not considered as statistically significant, the success rate was numerically higher in the acute phase. CONCLUSION: As a result, UCT applications provide thrombolysis especially in acute deep vein thrombosis, preventing deep venous insufficiency and especially post-thrombotic syndrome formation. UCT prevents bleeding complications by keeping thrombolytic amount low and can be used as an endovascular method of high safety in patient population with high bleeding complications such as patients with malignancies.

Effect of alprostadil on erythrocyte deformability in ischemia reperfusion injury.

BACKGROUND: Ischemia reperfusion injury (I/R) in lower extremity is a frequent and important clinical phenomenon. Protective effect of alprostadil on local and distant organ injury due to I/R has been well-documented but its effect on erythrocyte deformability needs further investigation. Our aim was to investigate the effect of alprostadil on erythrocyte deformability in infrarenal aorta of rats undergoing I/R. MATERIALS AND METHODS: Our study was conducted with 18 Wistar albino rats. Rats were divided into 3 groups; randomized control group (group C; n=6), I/R group without alprostadil (group I/R; n=6) and I/R group with alprostadil 20 mcg.kg(-1), intraperitoneal (group I/R-A; n=6). Packs of erythrocytes were prepared from heparinized blood samples and deformability measurements were done. RESULTS: Comparisons of the control and I/R-A groups revealed similar results (p=0.240). The values of the IR group were significantly higher than those of the control and IR-A groups (p=0.009, p=0.026, respectively). CONCLUSION: In our study, we detected unfavourable effects of I/R on erythrocyte deformability, which may lead to disturbance in blood flow and hence tissue perfusion in infrarenal rat aorta. We also found that alprostadil had beneficial effects by reversing undesirable effects of I/R (Fig. 1, Ref. 22).

The histopathological effects of levosimendan on liver injury induced by myocardial ischemia and reperfusion.

BACKGROUND: The aim of this study was to evaluate the histological and immunohistochemical effects of levosimendan on liver injury induced by myocardial ischemia and reperfusion (I/R) in a rat model. METHODS: Twenty-four male Wistar Albino rats were randomly divided into the four groups: Group C (Control, n = 6), Group I/R (n = 6), Group BI (I/R group treated with levosimendan before ischemia, n = 6), and Group AI (I/R group treated with levosimendan after ischemia, n = 6). Myocardial I/R was induced by ligation of the left anterior descending coronary artery for 30 min followed by two hours of reperfusion in I/R and I/R+Levosimendan groups. At the end of the study, liver tissue samples were obtained for histopathological and immunohistochemical examination. RESULTS: Masson Trichrome staining revealed significant hepatocyte degeneration and necrosis most marked in portal acinus Zone 3, especially around the central veins in Group I/R. Histopathological changes in Group AI were more similar to the changes in Group I/R. Milder hepatocellular degeneration was found in Group BI, when compared to groups I/R and AI. Immunohistochemical score was found to be significantly higher in Group I/R compared to groups C, BI and AI (p < 0.0001). The scores in groups BI and AI were found to be similar (p = 0.068). CONCLUSION: Levosimendan ameliorates liver injury induced by myocardial IR, especially when administered before induction of ischemia (Fig. 9, Ref. 37).

The effects of iloprost on lung injury induced by skeletal muscle ischemia-reperfusion.

PURPOSE: The aim of this study was to investigate the effects of iloprost (I) on lung injury as a remote organ following skeletal muscle ischemia-reperfusion injury in a rat model. MATERIALS AND METHODS: Twenty-four Wistar Albino rats were randomized into four groups (n = 6). Laparotomy was performed in all groups under general anesthesia. Only laparotomy was applied in Group S (Sham). Ischemia reperfusion group (Group I/R) underwent ischemia and reperfusion performed by clamping and declamping of the infrarenal abdominal aorta for 120 minutes. Group iloprost (Group I) received intravenous infusion of iloprost 0.5 ng/kg/min, without ischemia and reperfusion. Group I/R/I received intravenous infusion of iloprost 0.5 ng/kg/min immediately after 2 hours of ischemia. At the end of the study, lung tissue was obtained for determining total oxidant status (TOS) and total antioxidant status (TAS) levels, histochemical and immunohistochemical determination. RESULTS: Diffuse lymphocyte infiltration was detected in immunohistochemical examination of lung tissue in Group I/R. The connective tissue around bronchi, bronchioles and vessel walls was found to be increased. Although minimal local lymphocyte infiltration was detected in some fields in Group I/R/I, the overall tissue was found to be similar to Group S. iNOS expression was significantly higher in Group I/R, when compared with Group S and significantly lower in Group I/R/I compared to Group I/R.TOS levels were significantly higher in Group I/R, when compared with groups S and I (p = 0.028, p = 0.016, respectively) and significantly lower in group I/R/I, when compared with Group I/R (p = 0.048). TAS levels were significantly higher in Group I/R, when compared with groups S, I (p = 0.014, p = 0.027, respectively) and significantly lower in Group I/R/I, when compared with Group I/R (p = 0.032). CONCLUSION: These results indicate that administration of iloprost may have protective effects against ischemia reperfusion injury (Fig. 8, Tab. 1, Ref. 30)

The protective effects of dexmedetomidine on liver injury-induced myocardial ischemia reperfusion.

PURPOSE: The aim of this study was to evaluate the effect of dexmedetomidine (100 µg/kg-ip) on liver injury-induced myocardial ischemia and reperfusion (IR) in rats. MATERIALS AND METHODS: Twenty-four Wistar Albino rats were separated into four groups. There were four experimental groups (Group C (Control; n = 6), Group IR (ischemia-reperfusion, n = 6), Group D (Dexmedetomidine; n = 6) that underwent left thoracotomy and received ip dexmedetomidine without IR administered via 100 µg/kg ip route 30 minutes before ligating the left coronary artery, and Group IR-D (IR-Dexmedetomidine; n = 6). A small plastic snare was threaded through the ligature and placed in contact with the heart. To produce IR, a branch of the left coronary artery was occluded for 30 min followed by two hours of reperfusion. However, after the above procedure, the coronary artery was not occluded or reperfused in the control rats. At the end of the study, liver tissue was obtained for histochemical and immunohistochemical determination.Some part of tissue samples were stained with Masson-trichrome for the evaluation of ultrastructural changes and inducible nitric oxide synthase (iNOS) expression was evaluated in other part of samples for immunohistochemical examination. RESULTS: Histopathological changes were detected in Group IR when compared with Group C. iNOS expression was found to be increased and stronger particularly in the vascular wall, perisinusoidal space and hepatocytes around vena centralis in this group compared to the control group. Perivascular oedema was detected to be decreased in Group IR-D compared to Group IR. It was also observed that the impairment in the radial arrangement of hepatocytes significantly recovered in Group IR-D. The immunoreactivity was found to be significantly decreased in the assessment of iNOS expression in the same group when compared with Group IR. CONCLUSION: Administration of dexmedetomidine ameliorates liver injury induced by myocardial ischemia and reperfusion (Fig. 8, Ref. 33).

Antioxidative effects of adrenomedullin and vascular endothelial growth factor on lung injury induced by skeletal muscle ischemia-reperfusion.

PURPOSE: The aim of this study was to investigate the effects of adrenomedullin (AM) and vascular endothelial growth factor (VEGF) on lung injury as a remote organ following skeletal muscle ischemia-reperfusion injury in a rat model. MATERIALS AND METHODS: Thirty-six Wistar rats were randomized into six groups (n=6). Laparotomy was performed in all groups under general anesthesia. Nothing else was done in Group S (Sham). Ischemia reperfusion group (Group I/R) underwent ischemia and reperfusion performed by clamping and declamping of the infrarenal abdominal aorta for 120 minutes, respectively. Group VEGF and Group AM received intravenous infusion of VEGF (0.8 µg/kg) or AM (12 µg /kg) respectively, without ischemia and reperfusion. Group IR+VEGF and Group IR+AM received intravenous infusion of VEGF (0.8 µg/kg) or AM (12 µg /kg) respectively immediately after 2 hours period of ischemia. At the end of reperfusion period. Lung tissue samples were taken for biochemical examination. Total oxidant status (TOS) and total antioxidant status (TAS) levels in lung tissue were determined by using a novel automated method. p<0.05 was considered as statistically significant. RESULTS: TOS levels were significantly higher in Group I/R, when compared with groups S, AM and VEGF (p=0.004, p=0.011, p=0.017, respectively) and significantly lower in groups I/R+AM and I/R+VEGF, when compared with Group I/R (p=0.018, p=0.006, respectively). TAS levels were significantly higher in Group I/R, when compared with groups S, AM and VEGF (p=0.006 p=0.016, p=0.016, respectively) and significantly lower in Group I/R+AM, when compared with Group I/R (p=0.016). CONCLUSION: These findings indicate that AM and VEGF acted effectively on the prevention of lung injury induced by skeletal muscle ischemia-reperfusion injury in a rat model (Fig. 2, Ref. 30).

Is use of temporary pacing wires following coronary bypass surgery really necessary?

AIM: Temporary epicardial pacing wires (TEPW) which are routinely used after coronary bypass grafting may result in significant complications. We sought to identify variables that predict TEPW implantation and thereby limit their use. METHODS: This prospective study enrolled 564 patients (296 underwent coronary artery bypass grafting with cardiopulmonary bypass [ONCAB] and 268 underwent off-pump coronary artery bypass grafting, OPCAB). TEPW were placed in patients with the intraoperative presence of one or more of the following criteria: sinus bradycardia, sinus arrest, nodal/junctional rhythms, atrioventricular block, bundle branch block, ventricular tachycardia, or onset of atrial fibrillation. RESULTS: Only 31 (5.5%) patients [ONCAB: 20 (6.8%) (ventricular: 14, bichamber: 6); OPCAB: 11 (4.1%) (ventricular: 9, bichamber: 2)] had temporary epicardial pacing wires implanted intraoperatively. Indications for using temporary epicardial pacing wires for ONCAB were sinus bradycardia (8), nodal/junctional rhythms (3), atrioventricular block (3), atrial fibrillation (4), and bundle branch block (2), and for OPCAB were sinus bradycardia (8), nodal/junctional rhythms (2), and atrioventricular block (1). Mean duration for pacing was 22.4 h for the ONCAB group and 11.3 h for the OPCAB group. There were no temporary epicardial pacing wires associated complications. One paced OPCAB patient required a permanent pacemaker and 2 non-paced OPCAB patients required transvenous pacing wires. Univariate and multivariate analyses were also conducted to determine risk factors for TEPW. CONCLUSION: TEPW implantation is overused in cardiac surgery and by identifying independent predictors for pacing we conclude that TEPW use should be limited to a select few.

Occult malignancy in patients with venous thromboembolism: risk indicators and a diagnostic screening strategy.

BACKGROUND: The study was designed to analyse the risk indicators for a possible underlying malignancy and to evaluate whether extensive cancer screening is necessary in all patients with venous thromboembolism or not. METHODS: In total, 126 patients with idiopathic deep venous thrombosis, and 121 patients with secondary deep venous thrombosis of lower extremity and without a known malignancy were studied. A diagnostic screening workup including a clinical history, physical examination, complete blood count, blood sedimentation rate, basic biochemistry panel including hepatic and renal function tests, prostate-specific antigen, a chest X-ray and an abdominopelvic ultrasonography was performed for all patients. RESULTS: Suspicious findings suggesting an underlying cancer, previous history of venous thromboembolism, bilateral venous thrombosis and associated thrombosis in unusual sites were significantly more common in patients with idiopathic venous thrombosis. A malignancy was detected in 10 of the 126 patients (7.9%) without a known risk factor for deep venous thrombosis. During the follow-up period, a diagnosis of malignancy was established in two patients in the same group. CONCLUSION: The risk of an underlying malignancy in patients with idiopathic venous thromboembolism is significantly higher. A moderate screening strategy has the capacity to identify the majority of the malignancies in such patients. We advocate simple laboratory tests, a chest X-ray and an abdominopelvic ultrasonography in order to search for an occult malignancy. A more extensive screening strategy may be considered for patients with suspicious findings for cancer, recurrent or bilateral venous thromboembolism and associated thrombosis in unusual sites.

Transdiaphragmatic intercostal hernia following a penetrating thoracoabdominal injury: report of a case.

Intercostal hernias with abdominal viscera have rarely been reported following penetrating accidental or surgical trauma. We report herein a case of a traumatic rupture of the left hemidiaphragm, presenting as an intercostal hernia 2 years after a penetrating thoracoabdominal injury. The diaphragmatic rupture had been initially very small and could not be detected in the serial chest films and abdominal computed tomographic scans. The injury was also missed during an exploratory lateral thoracotomy. The patient was admitted with the chief complaint of a painful and gradually enlarging left-sided chest wall bulge of 8 months' duration. Surgery via an anterolateral thoracotomy along the axis of the intercostal hernia was performed, and the omentum and splenic flexura of the colon were reduced.

Descending necrotizing mediastinitis: a case report and review of the literature.

Descending necrotizing mediastinitis (DNM) is a highly fatal disease and as infection spreads along deep cervical planes into the mediastinum, widespread cellulitis, necrosis, abscess formation, and sepsis may occur. Early diagnosis is crucial for starting aggressive treatment without delay. Cervicothoracic computed tomography (CT) scanning may be useful for early diagnosis and preoperative evaluation of the surgical approach. Optimal treatment includes broad-spectrum antimicrobial therapy and extensive cervicomediastinal and transthoracic drainage. Clamshell incision provides an excellent exposure of both thoracic cavities and all mediastinal structures with minimal morbidity. We report here a fatal case of DNM with bilateral empyema and purulent pericarditis due to an odontogenic abscess with a brief review of the literature.

Biochemical and hemodynamic effects of ascorbic acid and alpha-tocopherol in coronary artery surgery.

This study was undertaken to evaluate the effects of alpha-tocopherol and ascorbic acid on markers of myocardial reperfusion injury and myocardial contractile function after coronary artery surgery. Forty-eight patients were divided into 4 groups; 300 mg/day alpha-tocopherol was given orally to the patients in group I for 14 days. In groups II and III, 4g of ascorbic acid was administered intravenously prior to induction and in the cardioplegic solution, respectively. Group IV was the control group. Blood samples were taken to determine the concentrations of creatine phosphokinase MB isoenzyme, malondialdehyde, uric acid, ascorbic acid and alpha-tocopherol in the perioperative period. Left ventricular functions were determined by means of MUGA scans and echocardiography preoperatively and on the 3rd and 7th days, postoperatively. The changes in serum creatine phosphokinase MB and malondialdehyde were significantly lower in study groups. when compared with the control group. We observed no significant changes in ventricular function, requirement for (+) inotropic agents and the incidence of ventricular arrhythmias among the groups, postoperatively. Biochemical findings are consistent with the free radical hypothesis. But we could not confirm these data with hemodynamic findings. This is probably due to the population of low-risk elective coronary surgery patients in this study.