Outcomes of Aortic Valve Replacement Via Right Anterior Minithoracotomy and Central Cannulation Versus Conventional Aortic Valve Replacement in Obese Patients

ABSTRACT Introduction: The minimally invasive implantation of aortic valve prosthesis via thoracotomy has numerous advantages and is comfortable, especially during the early postoperative period. Disadvantages of this method include peripheral vessel complications and groin infections. Central cannulation (direct aortic cannulation with superior vena cava cannulation) eliminates these drawbacks. In this report, we evaluated this method of treatment in patients with obesity. Methods: We retrospectively analyzed the medical records of 21 obese patients with severe aortic stenosis who underwent minimally invasive aortic valve implantation via thoracotomy and central cannulation with a bovine pericardial aortic prosthesis between 2017 and 2021. We compared these records with the medical records of 27 obese patients with severe aortic stenosis who underwent conventional aortic valve surgery. Results: Mean cross-clamp and cardiopulmonary bypass times were similar in both groups. Operating time was significantly longer in the minimally invasive group (P <0.05). In the minimally invasive group, acute renal failure occurred in 2 patients. In terms of postoperative complications, deep sternal wound infection/sternal instability was much higher in the conventional group. This was not statistically significant (P=0.090). Minimally invasive operated patients had a comfortable early postoperative period, with a mean visual analog scale for pain of 1.10±0.83 (no pain-mild pain). When we assessed patient satisfaction with the postoperative period, 13 patients were extremely satisfied, 7 patients were satisfied, and 1 patient was quite satisfied. Conclusion: Minimally invasive aortic valve implantation via thoracotomy and central cannulation is a safe and effective treatment for obese patients.

Endovascular treatment of Buerger's disease in patients with critical limb ischaemia.

OBJECTIVES: Thromboangitis obliteransis (TAO) is a nonatherosclerotic, inflammatory, occlusive arteritis that affects small and medium-sized arteries, veins and nerves. A large proportion of patients with TAO suffer from claudication, and the ultimate condition is gangrene and limb loss if there is no treatment or the cessation of smoking. Endovascular revascularisations are performed frequently and provide acceptable results in patients who are not suitable for surgery. In this study, we aimed to show our clinical experience in patients with TAO who were treated with endovascular revascularisation. METHODS: Between January 2014 and March 2020, 18 patients with lower-extremity critical limb ischaemia (CLI) underwent endovascular treatment (ET). Technical details and clinical success at follow up were documented. RESULTS: This study included 18 patients with lower-extremity TAO who presented with CLI and were treated with ET. The mean age of the patients was 38.8 ± 7.3 years. Fifty per cent of patients had pain at rest, 33.7% had minor tissue loss and non-healing ulcers, and 16.7% had major tissue loss on admission. The majority of lesions were located in the peroneal and tibial arteries (n = 13, 72.27percnt;). Two (11.1%) patients had distal superficial femoral artery occlusion concomitant with popliteal artery (PA) lesions, and three (16.7%) had PA occlusion concomitant with peroneal and tibial artery lesions. Re-establishment of antegrade flow in at least one vessel was achieved in 15 (83.3%) patients. Balloon angioplasty was performed in all patients. Plain old balloon angioplasty (POBA) was used in nine (60%) patients and drug-eluting balloon (DEB) angioplasty in six (40%). The mean duration of follow up in 15 patient who had undergone successful ET was 21.5 ± 8.1 months. The primary CLI-free rate at 12 and 24 months was 80% (66.7% in all patients). Secondary CLI-free rates at six, 12 and 24 months were 100, 93.3 and 53.3%, respectively. Patients who were active smokers during their follow up had a higher frequency of out-patient clinic consultations (p = 0.03). CONCLUSION: Controversy has continued on the role of ET in the treatment of TAO. This study shows that ET of TAO had promising primary and secondary patency rates with high technical success and limb-salvage rates.

Outcomes of Aortic Valve Replacement Via Right Anterior Minithoracotomy and Central Cannulation Versus Conventional Aortic Valve Replacement in Obese Patients.

INTRODUCTION: The minimally invasive implantation of aortic valve prosthesis via thoracotomy has numerous advantages and is comfortable, especially during the early postoperative period. Disadvantages of this method include peripheral vessel complications and groin infections. Central cannulation (direct aortic cannulation with superior vena cava cannulation) eliminates these drawbacks. In this report, we evaluated this method of treatment in patients with obesity. METHODS: We retrospectively analyzed the medical records of 21 obese patients with severe aortic stenosis who underwent minimally invasive aortic valve implantation via thoracotomy and central cannulation with a bovine pericardial aortic prosthesis between 2017 and 2021. We compared these records with the medical records of 27 obese patients with severe aortic stenosis who underwent conventional aortic valve surgery. RESULTS: Mean cross-clamp and cardiopulmonary bypass times were similar in both groups. Operating time was significantly longer in the minimally invasive group (P <0.05). In the minimally invasive group, acute renal failure occurred in 2 patients. In terms of postoperative complications, deep sternal wound infection/sternal instability was much higher in the conventional group. This was not statistically significant (P=0.090). Minimally invasive operated patients had a comfortable early postoperative period, with a mean visual analog scale for pain of 1.10±0.83 (no pain-mild pain). When we assessed patient satisfaction with the postoperative period, 13 patients were extremely satisfied, 7 patients were satisfied, and 1 patient was quite satisfied. CONCLUSION: Minimally invasive aortic valve implantation via thoracotomy and central cannulation is a safe and effective treatment for obese patients.

Midterm results of kissing stent reconstruction of the aortoiliac bifurcation.

PURPOSE: One subset of peripheral arterial disease is aortoiliac occlusive diseases (AIOD). AIOD is the term for all arterial lesions between the infrarenal distal aorta and common femoral artery. Implantation of kissing stents (KS) with covered stents (CS), bare-metal stents (BMS) is one of the endovascular treatment (ET) modalities for AIOD involving aortic bifurcation. In this study, we report the outcomes of the KS technique in infrarenal AIOD. METHODS: Between January 2014 and September 2017, 31 patients who underwent ET were treated with KS technique either with balloon-expandable BMS or balloon-expandable CS. Technical details, clinical success, complications, and patency at follow-up were documented. RESULTS: The majority of patients were male (77.4%), and the median age was 62 years (range, 45-78 years). All patients were classified according to the TASC II criteria. Eight patients (25.8%) were classified as TASC B. Fifteen patients (48.4%) were classified as TASC C, and 8 patients (25.8%) were classified as TASC D. These 23 patients were classified as complex AIOD group. BMS was used in 17 patients (54.8%), and CS was used in 14 patients (45.2%). Technical and clinical success was achieved in 100% of treated cases. The median follow-up was 24 months (range, 24-34 months). Primary patency rates at 12, 18, and 24 months after ET were 100%, 96.8%, and 90.3%, respectively. CONCLUSION: We found that the KS technique has satisfying 24-month results, even in complex AIOD lesions, with high technical success and acceptable midterm patency. Key Words: Aorta, Arterial occlusive diseases, Endovascular procedures, Iliac artery, Stents.

Outcomes of rheolytic thrombectomy in phlegmasia cerulea dolens.

OBJECTIVE: The purpose of this study was to assess the clinical features of phlegmasia cerulea dolens and present the treatment outcomes with rheolytic thrombectomy device. METHODS: From January 2014 and March 2019, 329 patients were diagnosed and hospitalized for acute iliofemoral deep vein thrombosis, and among those patients, seven patients diagnosed with lower extremity phlegmasia cerulea dolens were consecutively enrolled. Diagnosis of phlegmasia cerulea dolens was initially made on clinical findings followed by imaging with Doppler ultrasound. The rheolytic thrombectomy device was used in all patients with a combination of catheter-directed thrombolysis as an adjunctive therapy to facilitate more rapid thrombus clearance except for one patient who had a contraindication to the use of tissue plasminogen activator. RESULTS: Seven patients (four men, three women; median age, 63 years, range 52-68 years) were included. One patient had a relative contradiction to thrombolysis due to history of coronary artery bypass graft surgery; all other patients underwent pharmaco-mechanical thrombectomy with power pulse mode. The upper limit of 480 s was completed in all patients, and this time was not exceeded to prevent hemolysis-related complications. Six Fr catheters were used in four (57.1%) patients, and 8 Fr catheters were used in three patients (42.9%). Mean thrombolytic infusion duration was 28 ± 6.2 h for patients who received tissue plasminogen activator. After catheter-directed thrombolysis, total radiological success was achieved in two patients, and partial radiologic success was achieved in five patients; however, in all seven patients, clinical success was achieved. The mean duration for complete regression of cyanosis was 18.9 ± 8.1 h. Although no patients required blood replacement, mean decreases in hemoglobin and hematocrit were 2.7 ± 1.37 g/dl and 6.42 ± 4.47%, respectively. Acute kidney injury developed in three patients (42.9%). One patient required continuous renal replacement therapy. No cardiac complication was observed. One (14.3%) patient died of ventilator-related pneumonia on postprocedural day 10. The median duration of intensive care unit stay and hospital stay were 72 h (min-max: 24-264 h) and six days (min-max: 5-33 days), respectively. CONCLUSION: Rheolytic thrombectomy was less invasive and effective strategy for early stage phlegmasia cerulea dolens at creating rapid thrombus clearance to establish clinical success and facilitate more conservative management with catheter-directed thrombolysis.

Rotational atherectomy with adjunctive balloon angioplasty in calcified chronic total occlusions of superficial femoral artery.

OBJECTIVES: The aim was to report the mid-term outcomes of Jetstream™ rotational atherectomy device in complex femoropopliteal lesions. METHODS: Between November 2016 and April 2018, 55 patients who were treated with rotational atherectomy and adjunctive balloon angioplasty due to complex femoropopliteal lesions were retrospectively scanned. RESULTS: Fifty-five patients who underwent endovascular treatment with rotational atherectomy for chronic total occlusive femoropopliteal lesions were included in the study. Technical success rate was 100%. The mean age was 63 (±10.5) years. The cohort included 25 (45.4%) diabetics and 45 (81.8%) current smokers. The mean length of the lesions was 20.8 ± 11.2 cm. Chronic total occlusive lesions were detected in 35 (63.6%) patients, and mixed-type steno-occlusive lesions were detected in 20 patients (36.4%). Thirty-three (60%) lesions were moderate or severely calcified. Adjunctive balloon angioplasty was performed with plain old balloon angioplasty (POBA) on 31 (56.4%) patients and with drug-coated balloon angioplasty on 24 (43.6%) patients. After adjunctive balloon angioplasty, flow limiting dissection was observed in 20 (36.3%) patients, and 17 (30.9%) patients needed stent implantation. The Kaplan-Meier analysis method estimated that the overall primary patency rates at 12 and 24 months were 81.8% and 70.9%, respectively. Overall, secondary patency rates at 12 and 24 months were 94.5% and 80%. No statistically significant differences of 24-month primary patency and secondary patency rates were found between patients treated with drug-coated balloon angioplasty and POBA as an adjunctive therapy, even though primary patency (83.3% vs. 61.3%, p = .06) and secondary patency (91.7% vs. 71%, p = .56) rates of drug-coated balloon angioplasty were slightly higher than POBA. Patients with claudication had better primary patency (90.5% vs. 58.8%, p = .001) and secondary patency (100% vs. 67.6%, p = .004) rates than patients with critical limb ischemia at 24 months. Significant differences between patients who did and did not stop smoking were found in 24-month primary patency (57% vs. 88%, p = .007) and secondary patency (67% vs. 96%, p = .007). Six patients underwent unplanned amputation. There were eight (14.5%) mortalities during follow-up. CONCLUSIONS: Rotational atherectomy with adjunctive balloon angioplasty has satisfactory technical success rates and mid-term outcomes. As an adjunctive method, there was no difference between drug-coated balloon angioplasty s and POBAs. Smoking cessation is always the first-step treatment to improve mid-term patency results. Patients with critical limb ischemia have worse patency results compared to the patients with claudication.

Ultrasound-guided thrombin injection for treatment of iatrogenic femoral artery pseudoaneurysms compared with open surgery: first experiences from a single institution.

PURPOSE: The frequency of iatrogenic femoral artery pseudoaneurysm (FAP) diagnoses has recently increased due to the growing use of diagnostic and interventional procedures involving large diameter sheaths, as well as more potent anticoagulation procedures. In this study, we aimed to present our experience with ultrasound-guided thrombin injection (UGTI) in patients with iatrogenic FAP. METHODS: We studied patients with FAP who were under anticoagulant or antiplatelet therapies preoperatively, or who had received a loading dose during an interventional procedure. The outcomes of patients with FAP treated with UGTI were compared with those of patients who underwent open surgical repair for pseudoaneurysms. RESULTS: Among the 55 patients included in this study, 24 had UGTI while 31 had open surgery. The success rate was 95.8% when taking into consideration primary and secondary attempts. The mean duration of the procedure was shorter in patients with UGTI (10.1 ± 3.54 minutes) when compared with those who underwent open surgery (76.55 ± 26.74 minutes, P ≤ 0.001). In addition, the total complication frequency was significantly higher in the open surgery group (P = 0.005), as was their length of hospital stay (P < 0.001). Cost analysis showed significant differences between UGTI ($227.50 ± $82.90) and open surgery ($471.20 ± $437.60, P = 0.01). CONCLUSION: We have found that UGTI is the safer and more effective choice of treatment in appropriate patients with FAP, as opposed to surgery.

Preoperative Low-Molecular-Weight Heparin Prophylaxis Associated with Increased Heparin Resistance Frequency in On-Pump Coronary Artery Bypass Graft Surgery.

BACKGROUND: Unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) are being used for preoperative management of critical coronary artery disease. However, preoperative UFH therapy may cause a reduction in antithrombin concentrations, leading to various degrees of heparin resistance (HR). The main purpose of this study is to investigate the effects of preoperative LMWH on HR during cardiopulmonary bypass (CPB). METHODS: Data were retrospectively reviewed from adult patients that underwent on-pump coronary artery bypass graft (CABG) surgery. Four hundred fifty-seven patients underwent CABG, and 139 of them, who had isolated on-pump CABG, were included in the study. The heparin sensitivity index was calculated if activated clotting time levels were discovered below 400 seconds. Values less than 1.3 were accepted as HR. RESULTS: Of 139 patients who underwent on-pump CABG, preoperative LMWH was administered in 59 patients (56.8%). Intraoperative HR occurred in 29 patients (20.9%). Patients who received preoperative LMWH had an increased risk of developing HR compared with patients who did not receive LMWH (odds ratio 4.8 and 95% confidence interval 1.7-13.5). CPB duration and aortic clamp duration were significantly longer in patients who developed intraoperative HR when compared to those in patients who did not develop HR. CONCLUSION: Preoperative treatment with LMWH may cause intraoperative HR. Corrective and preventive arrangements with close follow-up should be performed in this group of patients.

Emerging biomarker for predicting acute kidney injury after cardiac surgery: cystatin C

Background/aim: Cardiopulmonary bypass (CPB)-associated acute kidney injury (AKI) is a common situation and rapid diagnosis and risk classification are important in the prevention and management of AKI. Changes in serum creatinine (SCr) levels in the current consensus criteria do not allow clinicians to diagnose CPB-associated AKI until 48 h after surgery. Materials and methods: We conducted a prospective single center study involving 57 patients who underwent cardiac surgery with CBP to compare serum beta-trace protein (BTP), neutrophil gelatinase-associated lipocalin-2 (NGAL), and cystatin C (CysC) levels with SCr for early diagnosis of CPB associated AKI. We defined AKI according to KDIGO criteria. Results: AKI was diagnosed in 24 (42.1%) patients. Mean duration of postoperative intensive care unit stay was 4.79 (± 6.12) days for the AKI+ group and 2.15 (± 0.56) days for the AKI­ group. The average length of hospital stay was 8.13 (± 5.75) days for the AKI+ group and 7.21 (± 3.68) days for the AKI­ group, which was significantly longer in the AKI+ group (P < 0.001, P = 0.011). Unlike other biomarkers, a significant increase in postoperative CysC levels was always found in patients with AKI during follow-up when compared to patients in whom AKI did not develop (P < 0.001). Conclusion: Increase in serum CysC levels showed a significant positive correlation with increase in SCr levels. We have not seen this correlation between other biomarkers and SCr. According to our study, serum CysC was a reliable biomarker that may aid in the early detection and follow-up of AKI after cardiac surgery.

Percutaneous Treatment of Deep Femoral Artery Pseudoaneurysm Due to Penetrating Trauma.

Pseudoaneurysm of the deep femoral artery (FAP) due to penetrating trauma is less common and can be a challenging condition for surgeons. The conventional treatment strategy for FAP due to penetrating trauma is open surgical repair. With emerging technologies, less invasive techniques are being used in these patients. We report a 37-year-old male patient with delayed presentation of FAP secondary to a stab wound and treated successfully with ultrasound-guided thrombin injection.

Endovascular Management of Right Subclavian Artery Pseudoaneurysm due to War Injury in Adolescent Patient.

Today there is a widespread use of endovascular treatment (EVT) for traumatic vascular injuries in adults, but there is lack of evidence of its use in adolescent patients with vascular injuries. With this case, we present successful EVT of 14-year-old adolescent with a right subclavian artery pseudoaneurysm (SAP) due to war injury. SAP was successfully excluded with deployment of 6 × 50 mm flexible, self-expanding covered nitinol stent graft (The GORE® VIABAHN® Endoprosthesis (W.L. Gore & Associates, Flagstaff, AZ)). Patient was discharged from hospital 2 days after the procedure with dual antiplatelet therapy (clopidogrel and aspirin). 3 months after discharge control DUS showed patent stent graft without any residual lesions. As a result, EVT is an alternative approach to treatment of SAP. It is safe, effective, and less invasive therapy for SAP in adults as well as in adolescents. We aim to contribute to the literature with this first case report.

The relationship between HbA1c & atrial fibrillation after off-pump coronary artery bypass surgery in diabetic patients.

OBJECTIVE: Diabetes mellitus is recognized as a risk factor for mortality and morbidity after coronary bypass grafting. We aimed to determine the association between preoperative hemoglobin HbA1c and AF after isolated off-pump coronary bypass grafting (OPCAB). METHODS: The seventy-two diabetic patients undergoing isolated off-pump coronary bypass grafting were retrospectively analyzed for AF. They were divided into; Low (4.8-5.4%), Medium (5.5-8%) and High (8.1-11.5%) groups. The three groups were compared with respect to demographic, echocardiographic, intraoperative and postoperative clinical characteristics correlation. RESULTS: Three patients died during postoperative period. AF occurred in 12 patients (16.6%) after surgery. The incidence of postoperative AF was 15.3% in the lower, 4.4% middle and 57.1% upper group. There was statistically significant correlation between preoperative HbA1C and preoperative stroke, preoperative MI history, Left atrial (LA) size, preoperative levosimendan, preoperative clopidogrel, postoperative AF, postoperative dopamine and dobutamine use, IABP, duration of extubation time, 24-hour chest tube drainage, duration of ICU and hospital mortality. Univariate logistic regression analysis showed significant correlation between postoperative AF and variables like preoperative HbA1c levels, LVEF<30%, history of preoperative MI, preoperative use of levosimendan, preoperative use of clopidogrel, postoperative dopamine, dobutamine adrenaline use, left atrium size, 24-hour chest tube drainage and length of stay in the intensive care unit. CONCLUSION: Preoperative HbA1c levels could predict the occurrence of postoperative AF in diabetic patients and may entail to administer protective strategies.