Analysis of a Large 19-Year Database in Vascular Surgery in Southern Iran: Evaluation of Trends and Limitations.

BACKGROUND: Large databases with data elements of clinical interest are essential for carrying out high-quality observational studies. Such databases have become increasingly popular for clinical research in fields like vascular surgery. Our goal is to create a solid and reliable database of the patients who have been admitted and undergone different vascular surgery procedures over 19 years and to provide surgeons with the current trends and limitations in managing patients with vascular disease. METHODS: The database of patients operated in Namazi Hospital, the referral center for vascular surgery in Southern Iran, from 2001 to 2019, was retrieved and patients undergoing vascular procedures were parted. Demographic and perioperative data were evaluated and patients were categorized into subgroups based on the type and cause of operation. All data were analyzed with SPSS version 26.0 (IBM, NY, USA). RESULTS: During the period of our study, a total of 226,051 operations were performed at the Namazi Hospital. Among these operations, 6,386 (2.82%) vascular surgery-related operations were entered into our study. The average age of the patients in our study was 53.22 ± 18.92 years (range: 1 day old-97 years) and 4,061 (63.6%) were male. Furthermore, 147 (2.3%) were operated by multiple surgeons. Moreover, 798 (12.5%) of the patients were admitted postoperatively to the intensive care unit, while the rest (5,588; 87.5%) in the common surgery ward. The cause of operation in 609 (9.5%) of the cases was trauma. Based on wound categorization, 5,132 (80.4%) were type I (clean). The most frequent operation performed in our center was arterial reconstruction and limb revascularization (31.4%), followed by hemodialysis access (31.3%). The most frequent surgery in the age group of less than 18 years was fasciotomy, in the 19-40 years group was tumor (56.8%) and varicose veins (52.9%), and in the 41-60 years group was implantation of ventral venous port catheter (47%). Only carotid and thoracic outlet syndrome surgeries were significantly higher in females. The remaining operations were all significantly higher among male patients. Finally, carotid body tumor surgery was the most frequent operation requiring intensive care unit monitoring. CONCLUSIONS: We demonstrated, for the first time, an overview of vascular surgeries performed in a referral tertiary center in Southwest Iran. There is an increase in the number of surgical procedures in the field of vascular surgery, and large databases will be a valuable tool for addressing critical problems in this field and also the healthcare system.

Senescent CD153+ T Lymphocytes Increase in the Peripheral Blood of Patients with Thromboangiitis Obliterans.

Background: Buerger's disease, also known as Thromboangiitis Obliterans (TAO), is a progressive, inflammatory vascular disease with unknown etiology. Objective: To address the degree of T cell immunosenescence in this inflammatory disease, the frequency of senescent T cells expressing CD57 and/or CD153 (CD30L) in patients with TAO. Methods: In this study, nine male cigarette smoker patients with TAO, nine male healthy cigarette smokers, and nine male healthy non-smoker blood donors were enrolled. PBMCs were extracted from the blood of all participants and stored in liquid nitrogen before use. The percentages of senescent T cells were detected by flow cytometry. The results were analyzed using non-parametric statistical tests. Results: The frequencies of senescent CD3+CD4+CD57+CD153+ and CD3+CD4+CD57-CD153+ T cells significantly increased in patients compared with the non-smoker controls (p=0.01 and p=0.04, respectively). The frequency of senescent CD3+CD4-CD57-CD153+ T cells was higher in patients compared with the smoker controls (p=0.02). In patients with TAO, CD57+CD153- cells were more frequent in CD3hiCD4- and CD3hiCD4+ T cells compared with the CD3loCD4- and CD3loCD4+ T cells (p=0.008 and p=0.0002, respectively). Conversely, the frequency of CD57-CD153+ T cells was significantly higher in CD3loCD4- T cells compared with the CD3hiCD4- T cells (p=0.004). The percentage of CD3+CD4+CD57+CD153- T cells correlated negatively with smoking level in smoker controls (p=0.02, Spearman r=-0.80). Conclusion: Elevated frequencies of senescent CD4+CD57+CD153+ and CD4+CD57-CD153+ T cells in patients compared with non-smoker and smoker controls suggest the contribution of immunosenescence in TAO.

Association of Complications During and After Carotid Body Tumor Resection with Tumor Size and Distance to the Base of Skull.

BACKGROUND: Depending on the size and location of the tumor, carotid body tumor (CBT) resection can come with various complications, mostly intraoperative bleeding, and cranial nerve injuries. In the present study, we aim to evaluate 2 fairly new variables, tumor volume, and distance to the base of the skull (DTBOS), with operative complications of CBT resection. METHODS: Patients who underwent CBT surgery in Namazi hospital from 2015 to 2019 were studied using standard databases. Tumor characteristics and DTBOS were measured via computed tomography or Magnetic resonance imaging. Outcomes, including intraoperative bleeding and cranial nerve injuries, along with perioperative data were collected. RESULTS: A total of 42 cases of CBT were evaluated with an average age of 53.21 ± 12.8 and mostly female (85.7%). Based on Shamblin scoring, 2 (4.8%) were classified as group I, 25 (59.5%) as group II, and 15 (35.7%) as group III. The amount of bleeding significantly increased with an increase in the Shamblin scores (P = 0.031; median: I: 45 cc; II: 250 cc, III: 400 cc). Also, there was a significant positive correlation between the size of the tumor and the estimated amount of bleeding (correlation coefficient = 0.660; P < 0.001), and also a significant reverse correlation with between bleeding and DTBOS (correlation coefficient = -0.345; P = 0.025). During the follow-up of the patients, 6 (14.3%) had abnormalities in their neurological evaluation. Receiver operating characteristic curve analysis revealed the size of tumor cutoff level 32.7 cm3 (3.2 cm radius) to be most predictive of postoperative neurological complication with an area under the curve = 0.83, sensitivity = 83.3%, specificity = 80.6%, a negative predictive value = 96.7%, and positive predictive value of 41.7%, and an accuracy of 81.0%. Furthermore, based on the predictive power of the models in our study, we demonstrated that a combination model including the tumor size, DTBOS, along with the Shamblin score had the most predictive power for neurological complications. CONCLUSIONS: By evaluating CBT size and DTBOS, paired with the use of the Shamblin classification, a better, more insightful understanding of possible risks and complications of CBT resection can be obtained, leading to deserved levels of patient care.

Uncontrollable Bleeding Managed by Thoracic Gauze Packing in Blunt Traumatic Aortic Injury.

Blunt traumatic aortic injury is a deadly phenomenon in traumatic injuries. Damage control is essential in the management of traumatic patients. We reported a 20-years-old man brought to the trauma center from a car turnover crash scene. Blunt traumatic aortic injury grade III was revealed by contrast-enhanced computed tomography requiring urgent intervention. After an uneventful open repair of the aorta with Dacron graft, diffuse blood oozing occurred from the mediastinum and left pleural cavity. We packed the thoracic bleeding sites and removed the packings after four days. The patient developed no signs of cardiopulmonary compromise until the removal of the packings. Later, the patient was discharged with no complications. Through the follow-ups, he had no complaint regarding the surgery. The patient has a normal chest x-ray one year later. Thoracic gauze packing is limitedly practiced due to concerns for cardiopulmonary compromises. To the best of our knowledge, this is the first time that this technique has been performed in the open repair of blunt traumatic thoracic aortic injury as damage control.

Great saphenous vein aneurysm mimicking inguinal hernia: a case report.

BACKGROUND: Diagnosis of venous aneurysm may be difficult and can be misjudged as mass-like lesions, including hernias. Here we present the case of a patient with a great saphenous vein aneurysm misdiagnosed and operated as an inguinal hernia. CASE PRESENTATION: A 39-year-old Middle Eastern/Persian male presented with left inguinal bulging 15 years ago, which was misdiagnosed and operated on with a diagnosis of inguinal hernia. He was referred to our clinic, in which color Doppler sonography revealed left-sided saphenofemoral junction incompetence with severe flow reversal during the Valsalva maneuver, in favor of a great saphenous vein aneurysm. Ligation of left saphenofemoral junction and stripping of saphenous vein, and stab avulsion phlebotomy of left lower extremity varicose veins, were done. He was discharged the next day after the operation with an uneventful postoperative course or complication on follow-up. CONCLUSION: Venous aneurysms can be misdiagnosed as other, more common, mass-like lesions, such as inguinal hernias. Therefore, our report emphasizes the consideration of thorough assessment and utilization of color duplex sonography to prevent further misdiagnosis and unnecessary intervention and operations.

Effective treatment of intractable diseases using nanoparticles to interfere with vascular supply and angiogenic process.

Angiogenesis is a vital biological process involving blood vessels forming from pre-existing vascular systems. This process contributes to various physiological activities, including embryonic development, hair growth, ovulation, menstruation, and the repair and regeneration of damaged tissue. On the other hand, it is essential in treating a wide range of pathological diseases, such as cardiovascular and ischemic diseases, rheumatoid arthritis, malignancies, ophthalmic and retinal diseases, and other chronic conditions. These diseases and disorders are frequently treated by regulating angiogenesis by utilizing a variety of pro-angiogenic or anti-angiogenic agents or molecules by stimulating or suppressing this complicated process, respectively. Nevertheless, many traditional angiogenic therapy techniques suffer from a lack of ability to achieve the intended therapeutic impact because of various constraints. These disadvantages include limited bioavailability, drug resistance, fast elimination, increased price, nonspecificity, and adverse effects. As a result, it is an excellent time for developing various pro- and anti-angiogenic substances that might circumvent the abovementioned restrictions, followed by their efficient use in treating disorders associated with angiogenesis. In recent years, significant progress has been made in different fields of medicine and biology, including therapeutic angiogenesis. Around the world, a multitude of research groups investigated several inorganic or organic nanoparticles (NPs) that had the potential to effectively modify the angiogenesis processes by either enhancing or suppressing the process. Many studies into the processes behind NP-mediated angiogenesis are well described. In this article, we also cover the application of NPs to encourage tissue vascularization as well as their angiogenic and anti-angiogenic effects in the treatment of several disorders, including bone regeneration, peripheral vascular disease, diabetic retinopathy, ischemic stroke, rheumatoid arthritis, post-ischemic cardiovascular injury, age-related macular degeneration, diabetic retinopathy, gene delivery-based angiogenic therapy, protein delivery-based angiogenic therapy, stem cell angiogenic therapy, and diabetic retinopathy, cancer that may benefit from the behavior of the nanostructures in the vascular system throughout the body. In addition, the accompanying difficulties and potential future applications of NPs in treating angiogenesis-related diseases and antiangiogenic therapies are discussed.

The Role of Surgical and Endovascular Repair of Blunt Traumatic Aortic Injury in the Modern Era: A Single-Center Experience.

Objective: To evaluate the efficacy of chest x-ray (CXR) in blunt traumatic aortic injury (BTAI) as a primary imaging tool in trauma patients. Methods: We retrospectively reviewed our hospital records for blunt thoracic aortic injury patients who had a therapeutic intervention from January 2015 to February 2021. Patients' characteristics, initial chest x-rays, and computed tomography (CT) scan were extracted and re-evaluated. Results: Eighteen patients matched the criteria of our research. The mean age and the injury severity score (ISS) was 29.8±11.2 and 38.4±14.4, respectively. Seven patients (38.9%) underwent thoracic endovascular aortic repair (TEVAR), and 11 (61.1%) had open surgery. The TEVAR group had significantly lower mean intensive care unit stay days (6.6±3.9 vs. 10.8±6.9 in open aortic repair (OAR), p<0.05). The percentile of patients requiring blood transfusion was significantly lower in the TEVAR group (57% vs. 100% in OAR, p<0.05). Mediastinal widening (66.7%) was the most common finding during the evaluation of initial chest x-rays. Interestingly, 22.2% of the initial x-rays were not remarkable for BTAI. Conclusion: TEVAR is an advantageous choice in the management of BTAI. However, open aortic repair is the optimal decision in certain situations. It is suggested that the Interventional management of the BTAI must be performed by experienced vascular surgeons in a medical center capable of both OAR and TEVAR.

The role of routine chest radiography after implantable venous access port catheter insertion under the guide of ultrasonography and fluoroscopy.

BACKGROUND: The objective of this study is the evaluation of routine chest radiography following the placement of Implantable venous access port catheter (IVAPC) central lines using combined ultrasound and fluoroscopic guidance by a vascular surgeon in the operating room. MATERIAL AND METHOD: A prospective study of 189 consecutive patients who underwent IVAPC central line insertion in the vascular surgery operating room from 2016 to 2019. Venipuncture was performed with an 18-gauge needle under the guidance of sonography in each case, and the access site was noted. The line position was confirmed by fluoroscopy following the procedure. Multiple tries for puncture and patients under 18 were excluded from our study. Routine radiography of chest was performed for all patients and pneumothorax, hemothorax, and catheter malposition were evaluated in each case. RESULTS: There were 2 cases of asymptomatic pneumothorax, no cases of hemothorax, and all catheter tip positions were optimal or acceptable. The annual cost of chest radiography was 33,000,000IRR, 220 h of hospital and staff time, and 1.1 mSv radiation. CONCLUSION: In conclusion, when imaging guidance is used for IVAPC insertion by an experienced surgeon in a high-volume center, performing post-procedure routine chest radiography shows little benefit.

Simultaneous retrograde venous and anterograde arterial bullet embolism: a case report.

BACKGROUND: Bullet embolus is a rare condition following gunshot injuries and represents a clinical challenge regarding both diagnosis and management. CASE PRESENTATION: We report the case of a 35-year-old Iranian (Middle-Eastern) male patient with a shotgun injury to both buttocks, which traveled to the heart and the popliteal area through the femoral vein and superficial femoral artery, respectively. Surgical intervention was applied for the popliteal pellet, and the patient was discharged without further complications. CONCLUSION: Although bullet emboli can be a clinical challenge, with the advent of modern procedures, removal has become safer. X-ray, computed tomography, and transthoracic and/or transesophageal echocardiography may be used as adjuncts to help establish the diagnosis.

Complete internal carotid artery coil after huge carotid body tumor resection.

In this brief article, we present an 82-year-old female who came to our care due to a carotid body tumor of the right side of the neck. After an uneventful removal of the tumor, we discovered a 360-degree coil in the internal carotid artery which was not observed in the preoperative imaging. After resection, we believe that the free space left by the large tumor and prior mass effect of the tumor on the internal carotid artery have led to carotid coiling.

Main Bronchus Penetration by Thoracostomy Tube: A Rare Inadvertent Complication.

Tube thoracostomy has been known to be a common and invasive, however not innocuous, procedure which is often life-saving. Though, numerous complications have been reported during executing this procedure. In this report, we describe a 27-year-old woman, case of multiple trauma due to car collision that was transferred to our service due to severe right side chest tube air leak and subcutaneous emphysema in which after proper evaluation, it was revealed that the chest tube crossed through the right pleural cavity and penetrated the bronchus intermedius. A literature search failed to identify a similar case. The misplacement was confirmed by fiber optic bronchoscopy and after surgical and intensive care management of the patient, she was discharged with an uneventful post-op course. This case noticeably determines that bearing in mind the extreme risks and the careful checks of the tube location are required, particularly in trauma patients, even in the absence of anatomical abnormalities.

Massive hemoptysis following cannulation of right internal jugular vein for insertion of cuffed hemodialysis catheter: A rare complication of central venous catheterization.

Here we report an extremely rare presentation of internal jugular vein catheterization, presenting as massive hemoptysis which was noted during right internal jugular vein cuffed hemodialysis catheter insertion of a 39-year-old man known-case of End-Stage Renal Disease. Chest roentgenogram and computerized tomography scan showed pleural effusion and misplacement of the tip of hemodialysis catheter in the posterior mediastinum causing possible damage to the right main bronchus. After chest tube insertion and removing the misplaced hemodialysis catheter, a proper cuffed catheter was inserted and the patient was discharged with an uneventful post-op course.

Memory T cells of patients with abdominal aortic aneurysm differentially expressed micro RNAs 21, 92a, 146a, 155, 326 and 663 in response to Helicobacter pylori and Lactobacillus acidophilus.

Regarding the role of micro RNAs (miRNA) in the proliferation and differentiation of T cells as well as the controversy around the role of bacteria in the pathogenesis of abdominal aortic aneurysm (AAA), the effects of Helicobacter pylori (Hp) and Lactobacillus acidophilus (La) were investigated in the induction of miRNAs and apoptosis in CD4+ memory T (Tem) cells of AAA patients and controls. Signature atherosclerosis miRNAs 21, 92a, 146a, 155, 326 and 663 were measured in the sera and tissues of AAA patients and control. PBMCs separately and in co-culture with HUVEC were treated with Hp-water-extract (HpWE) and La-conditioned-medium (LaCM). Apoptosis and miRNA levels were assessed in the isolated Tem by flowcytometry and real-time-PCR. In single-culture, HpWE increased apoptosis and miR-155 and LaCM decreased apoptosis and increased miR-21. In co-culture, apoptosis decreased in both groups in response to CagA+HpWE. Also, all miRNAs increased in patients Tem but in controls, only miR- 146a and 21 showed changes. Although, apoptosis was similar in Tem of patients and controls, the effects of Hp and La were different on the induction of apoptosis and miRNAs and also these bacteria showed different impacts in single and co-culture conditions. Beyond the direct effects of these bacteria on the pathogenesis of diseases, their effects on miRNAs expression may shed light on their roles in the development and the prevention of AAA.

High Flow Scalp Arteriovenous Malformation: A Case Report.

Scalp arteriovenous malformations (AVMs) are abnormal vascular lesions, which can be managed effectively and safely with surgical or endovascular approaches. Here, we discuss a case of scalp AVM malformation in a 25-year-old female, in which due to the proximity of the feeder artery to right orbit, surgical excision was preferred and the AVM was excised with an uneventful post-op course.

Internal Jugular Vein Injury by Fishbone Ingestion.

Fishbone ingestion is a common occurrence in the Middle East countries. We present a patient with a unique complication of fishbone ingestion. A 65-year-old woman presented with left-sided neck pain and swelling since 5 days before admission. A linear foreign body with horizontal orientation was seen in CT scan at the superior part of the pharynx along with a collection around it which caused a laceration on the medial aspect of internal jugular vein and thrombosis inside the internal jugular vein.

Aneurysm of the Internal Carotid Artery Misdiagnosed as Cervical Paraganglioma; A Case Report and Literature Review.

The aneurysms of the extracranial segment of the internal carotid artery are not common and are associated with severe neurologic deficits. They could be misdiagnosed with several lesion of the cervical region. We herein report a case of internal carotid artery aneurysm misdiagnosed as paraganglioma. A 23-year-old man presented with progressive growing mass in right enlarging mass in the upper part of the neck below the angle of the mandible. The patient underwent surgery by the ear, nose, throat (ENT) surgeon through submandibular approach with impression of paraganglioma but severe pulsatile bleeding was encountered intraoperatively. Two vascular clamps were applied and the patient was transferred to the vascular ward. Computerized tomography (CT) angiogram revealed a huge aneurysm of the internal carotid artery in the extracranial segment with injured wall. After 2 days of medical therapy the patient was transferred to the operating room and the aneurysm was repaired using Dacrons. The patient had an uneventful hospital course and was asymptomatic after 1 year of follow-up. Precise preoperative assessment and evaluation with different modalities should be performed to avoid fatal complications. Surgery is a safe and effective method in experienced hands for repair of such aneurysms.

Tube Thoracostomy (Chest Tube) Removal in Traumatic Patients: What Do We Know? What Can We Do?

Chest tube (CT) or tube thoracostomy placement is often indicated following traumatic injuries. Premature movement of the chest tube leads to increased hospital complications and costs for patients. Placement of a chest tube is indicated in drainage of blood, bile, pus, drain air, and other fluids. Although there is a general agreement for the placement of a chest tube, there is little consensus on the subsequent management. Chest tube removal in trauma patients increases morbidity and hospital expense if not done at the right time. A review of relevant literature showed that the best answers to some questions about time and decision-making have been long sought. Issues discussed in this manuscript include chest tube removal conditions, the need for chest radiography before and after chest tuberemoval, the need to clamp the chest tube prior to removal, and drainage rate and acceptability prior to removal.

Blood flow parameters of the central retinal and internal carotid arteries in asymmetric diabetic retinopathy.

PURPOSE: To investigate the correlation between diabetic retinopathy severity and blood flow parameters in the central retinal artery (CRA) and internal carotid artery (ICA). METHODS: This comparative study included 40 eyes of 20 patients with asymmetric diabetic retinopathy. Twelve subjects had asymmetric diabetic macular edema while eight patients had proliferative diabetic retinopathy (PDR) in one eye and non-proliferative diabetic retinopathy (NPDR) in the fellow eye. Bilateral color Doppler imaging (CDI) of the CRA and ICA was performed to determine resistance index (RI) and peak systolic velocity (PSV). RI and PSV values were compared between eyes with higher grades of macular edema (> 2 grades of difference with the fellow eye) and fellow eyes with less severe macular edema, as well as between eyes with PDR and fellow eyes with NPDR. RESULTS: Mean RI of the CRA in eyes with higher grades of macular edema was 0.78±0.11 as compared to 0.69±0.08 in fellow eyes with less severe macular edema (P=0.012), while PSV of the CRA was 58.83±18.93 cm/s in eyes with higher grades of macular edema versus 59.75±11.83 cm/s in fellow eyes with less severe macular edema (P=1.00). Mean PSV of the ICA was 55±23.94 cm/s in eyes with PDR and 69.25±34.30 cm/s in eyes with NPDR (P=0.008) while mean RI of the ICA was 0.81±0.13 in eyes with PDR and 0.76±0.12 in eyes with NPDR (P=1.00). CONCLUSION: Evaluation of RI in the CRA and PSV in the ICA by CDI in diabetic patients may identify eyes at risk of more severe macular edema and PDR.