National guidelines on the management of venous thromboembolism: Joint guideline of the Turkish Society of Cardiovascular Surgery, National Society of Vascular and Endovascular Surgery, and Phlebology Society.

These evidence-based guidelines from the Turkish Society of Cardiovascular Surgery, National Society of Vascular and Endovascular Surgery, and Phlebology Society intend to support clinicians in best decisions regarding the treatment of venous thromboembolism (VTE). The Editor was selected by the three national societies and was tasked with the recruitment of the recognized panel. All financial support was solely derived from the sponsoring societies without the direct involvement of industry or other external stakeholders. The panel prioritized clinical questions and outcomes according to their importance for clinicians in terms of VTE. The panel agreed on 42 recommendations under 15 headings for the diagnosis, initial management, secondary prevention of VTE, and treatment of recurrent VTE events. Important recommendations included the use of ultrasonography, preference for home treatment over hospital treatment for uncomplicated VTE, preference for direct oral anticoagulants (DOACs) over vitamin K antagonists for primary treatment of cancer and non-cancer-related VTE, extended or indefinite anticoagulation with DOACs in selected high-risk patients. Early catheter-directed thrombectomy was recommended in only young symptomatic patients with a diagnosis of fresh iliofemoral deep vein thrombosis.

Current surgical approaches in Takayasu's arteritis: a single-centre experience.

OBJECTIVES: We investigated cardiovascular surgical interventions in a group of patients with Takayasu's arteritis (TAK) diagnosed and followed by a single centre. METHODS: . Twenty patients with TAK (5 males, 15 females, mean current age: 38.1±10.7) who were operated for a broad spectrum of cardiovascular diseases ranging from coronary heart disease to coeliac stenosis or aneurysm between July 2008 and April 2016 were studied. One patient underwent operation related to aneurysm of ascending aorta and aortic insufficiency, 2 patients had operations for both coronary arteries originating from aortic arch, 6 patients for only arteries originating from aortic arch, 1 patient for both carotid and infra-inguinal artery, 5 patients for aorta-iliac or femoral revascularisation, 5 patients for renal artery and/or coeliac or superior mesenteric artery revascularisations. Three of these interventions were endarterectomy and patch plasty. RESULTS: The mean time between diagnosis and surgical intervention was 6.1±3.1 years (range: 3 months-12 years). A total of 4/32 (12.5%) grafts were occluded during the follow up period of mean 39.2±24.6 months. Secondary interventions like cross-femoral, or graft to superficial femoral artery bypasses were needed in 2 patients who underwent aorta-bifemoral bypasses to keep patency. There was no operative mortality. We did not observe any anastomotic aneurysm. One patient died due to graft infection 3 months after the operation. Stroke occurred in 2 patients who underwent re-vascularisations of the arteries originating from aortic arch. CONCLUSIONS: In our series, we have a relatively good midterm patency rates in patients with TAK and did not observe any anastomotic pseudoaneurysm. Stroke developed in 2 patients and mortality occurred in one patient due to the graft infection 3 months after the operation. In patients with limited carotid or aorta-iliac stenosis, chance for endarterectomy should be evaluated. Well-controlled disease activity with intensive medical treatment and multi-disciplinary approach could be associated with a favourable long-term outcome.

[Approach to venous diseases in the elderly]. / Yaslilarda ven hastaliklarina yaklasim.

Incidence and severity of both deep vein thrombosis and chronic venous insufficiency are increased with age. Today, however, the significance of these diseases in the elderly patient population are still poorly comprehended. Although most patients have a history of previous treatment, chronic venous insufficiency is usually encountered in the advanced clinical stage. As a result, there is an increase in mobility restrictions, the need for assistance in daily activities and the risk of falls in elderly patients. The quality of life is negatively affected in patients. Age, immobilization and obesity are the main risk factors for the development of chronic venous insufficiency in the elderly. Patients present with complaints such as pain, edema, burning, bloating, weight sensation, restless leg syndrome, night cramps, varicosities, color change and open wound in the legs. In diagnostic procedures, color Doppler ultrasonography examination is used together with patient's staging as well as history and physical examination. Classification of "Clinical-Etiology- Anatomy-Pathology (CEAP)" is used in defining venous insufficiency patients. Among the leading differential diagnoses are congestive heart failure, renal failure, liver dysfunction, antihypertensive, non-steroidal anti-inflammatory and some antidiabetic medications and lymphedema and deep vein thrombosis. Patients underwent early diagnosis and long-term regular follow-up after appropriate therapeutic interventions reduce the risk of developing advanced complicated clinical conditions. The main components of treatment include patient education, mobilization, leg elevation, prevention of obesity, use of venous compression stockings, use of venoactive agents, and catheterbased/ surgical interventions. Endovenous radiofrequency or laser ablation techniques and endovenous chemical ablation techniques in superficial venous insufficiency are preferential interventional modalities due to low morbidity risks in older age group of chronic superficial venous insufficiency patients. Foam sclerotherapy for superficial truncal varicosities can also be considered as an alternative for older age groups. In any treatment decision to be taken, the risk-benefit ratio, the patient's clinical status, the available treatment options as well as the patientspecific risks and the patient's expectation and decision should be the main determinant. It is important to remember that what is more important than the age of the patient is the patient's own physical condition and that the quality of life is improved.

Ablation of the great saphenous vein with nontumescent n-butyl cyanoacrylate versus endovenous laser therapy.

OBJECTIVE: The endovenous application of n-butyl cyanoacrylate (NBCA) is a new nontumescent ablation technique for the treatment of venous insufficiency. The aim of this study was to retrospectively compare an NBCA-based ablation method with endovenous laser ablation (EVLA) for the management of incompetent great saphenous veins. METHODS: Between May 2013 and August 2014, there were 339 patients with incompetent varicose veins who were treated with either the endovenous application of NBCA (VariClose Vein Sealing System [VVSS]; Biolas, Ankara, Turkey) or EVLA. The preprocedural, intraprocedural, postprocedural, and follow-up data of the patients were collected and retrospectively compared. RESULTS: The mean age was 45.09 ± 12 years in the VVSS group and 47.08 ± 11 years in the EVLA group (P = .113). The average ablated vein length was 31.97 ± 6.83 cm in the VVSS group and 31.65 ± 6.25 cm in the EVLA group (P = .97). The average tumescent anesthesia use was 300 mL (range, 60-600 mL) in the EVLA group. The average procedure time was 7 minutes (range, 4-11 minutes) in the VVSS group and 18 minutes (range, 14-25 minutes) in the EVLA group (P < .01). On the basis of ultrasound examinations performed at the end of the procedure, all procedures in both groups were successful, and the target vein segments were fully occluded. The 12-month total occlusion rates in the VVSS and EVLA groups were 98.6% and 97.3%, respectively (P = .65). In both the VVSS and EVLA groups, the Venous Clinical Severity Score declined significantly with no difference between groups. There were fewer adverse events after VVSS treatment compared with EVLA treatment (pigmentation, P ≤ .002; phlebitis, P ≤ .015). There was no need for tumescent anesthesia in the VVSS group. CONCLUSIONS: The NBCA-based vein sealing system is a fast and effective treatment option for the management of incompetent saphenous veins that does not involve tumescent anesthesia, compression stockings, paresthesia, burn marks, or pigmentation. Further large-scale studies with long-term outcomes are required to identify the optimal treatment modalities for patients with saphenous vein insufficiency.

A prospective comparison of a new cyanoacrylate glue and laser ablation for the treatment of venous insufficiency.

INTRODUCTION: Cyanoacrylate ablation is the newest nonthermal vein ablation technique. The one-year results of a prospective comparative study of a new cyanoacrylate glue versus endovenous laser ablation for the treatment of venous insufficiency is presented. MATERIAL AND METHODS: A total of 310 adult subjects were treated with cyanoacrylate ablation or endovenous laser ablation. The primary endpoint of this study was complete occlusion of the great saphenous vein. Secondary endpoints were procedure time, procedural pain, ecchymosis at day 3, adverse events, changes from baseline in Venous Clinical Severity Score, and Aberdeen Varicose Vein Questionnaire. RESULTS: Operative time was shorter (15 ± 2.5 versus 33.2 ± 5.7, <0.001), and periprocedural pain was less (3.1 ± 1.6 versus 6.5 ± 2.3, <0.001) in cyanoacrylate ablation group compared to the endovenous laser ablation group. Ecchymosis at the third day was also significantly less in cyanoacrylate ablation group (<0.001). Temporary or permanent paresthesia developed in seven patients in endovenous laser ablation group and none in cyanoacrylate ablation group (p = 0.015). One, three, and 12 months closure rates were 87.1, 91.7, and 92.2% for endovenous laser ablation and 96.7, 96.6, and 95.8% for cyanoacrylate ablation groups. Closure rate at first month was significantly better in cyanoacrylate ablation group (<0.001). Although there is a trend of better closure rates in cyanoacrylate ablation patients, this difference did not reach to the statistical difference at sixth and 12th month (p = 0.127 and 0.138, respectively). Both groups had significant improvement in Venous Clinical Severity Score and Aberdeen Varicose Vein Questionnaire postoperatively (<0.001), but there was no significant difference in Venous Clinical Severity Score and Aberdeen Varicose Vein Questionnaire scores between the groups at first, sixth, and 12 months. Only a slightly better well-being trend was noted in cyanoacrylate ablation group in terms of Aberdeen Varicose Vein Questionnaire scores (p = 0.062). CONCLUSIONS: The efficacy and safety analysis shows that cyanoacrylate ablation is a safe, simple method which can be recommended as an effective endovenous ablation technique. The follow-up data more than one year will clarify the future role of cyanoacrylate ablation for the treatment incompetent great saphenous veins.

A stable prostacyclin analogue (iloprost) in the treatment of Buerger's disease: a prospective analysis of 150 patients.

PURPOSE: To assess the efficacy and of iloprost in the treatment of Buerger's disease. METHODS: In this prospective study, 158 patients with rest pain and/or ischemic ulcers from 17 clinics were administered 1 ng/kg/min intravenous iloprost for 28-days. The primary endpoint was complete healing without pain or major amputation at 24 weeks. The secondary endpoints were pain assessment, reduction in ulcer area, 50% reduction of the ulcer size, shift in the modified SVS/ISCVS clinical status grading scale, global assessment by the investigator and an independent observer at 4 and 24 weeks. The comparisons were carried out with the initial values. The final evaluation was carried out in 150 patients. RESULTS: Complete healing rate was significantly better with iloprost treatment in comparison to the initial values at 24 weeks (<0.001). The secondary endpoints; complete healing rate, pain, the size of the ulcer, 50% reduction of the ulcer size, SVS/ISCVS grading scale, assessment by investigator, assessment by observer parameters were significantly better at 4 and 24 weeks (<0.001). The reduction of the ulcer size was significantly better when comparing 4th and 24th week values (<0.05). CONCLUSION: The results of this independent study indicate that intravenous iloprost relieves ischemic symptoms efficiently in the acute phase Buerger's disease patients. Considering unsatisfactory results following surgical revascularisation and sympathectomy in Buerger's disease, prostacyclin analogues might be the first line treatment as long as complete abstinence from smoking is achieved.

The in vitro effects of iloprost with other vasodilators on the human internal thoracic artery.

PURPOSE: We aimed (a) to analyze the effects of iloprost as a vasodilator on the human internal thoracic artery (ITA) and (b) to compare these effects with the effects of other vasodilators now being used in the clinic. METHODS: Following transfer into only Krebs solution or into Krebs solution containing papaverine or iloprost, human ITA strips were then incubated only in Krebs or in Krebs with vasodilators that are generally used in clinical practice, such as diltiazem or glyceryl trinitrate. Cumulative concentration-contraction curves for noradrenaline (NA) and KCl were then established for these strips. Student's t-test and one-way analysis of variance followed by Tukey-Kramer tests were used to compare differences between groups. A p <0.05 was used to indicate significance. RESULTS: Among the transfer solutions, papaverine (6.50 ± 0.20) and iloprost (7.33 ± 0.13) were significantly more potent than Krebs (8.46 ± 0.75, p <0.001 and p <0.05) with regard to preventive effect on precontracted ITA with NA. Iloprost significantly relaxed the NA-induced precontracted ITA strips in the Krebs, papaverine, and iloprost groups. Diltiazem significantly relaxed the precontracted ITA with KCl in all storage groups. CONCLUSION: Iloprost may also prevent perioperative ITA spasm, but should be tested in the clinical setting.

Angiographic characteristics of major intramural coronary arteries and their effect on coronary bypass surgery.

OBJECTIVE: Dissection of intramyocardial coronary arteries can cause technical problems in coronary bypass surgery, including bleeding and inadvertent ventricular perforation, which can prolong the operation time. The goal of this study was to assess the effects of intramural coronary arteries on coronary bypass surgery and to define the angiographic characteristics of these coronary arteries. METHODS AND RESULTS: We studied 112 patients (60.12 +/- 10.23 y, 98 M) who underwent coronary bypass surgery, half of whom had intramural coronary arteries. Coronary angiographies were revised just after surgery, and characteristics of intramural coronary arteries were documented by combining surgical findings and angiographies. In angiographic examinations, studied intramural segments of the coronary arteries had less angulations in contrast to matched segments of control groups (mean 1.1 +/- 0.3 vs. 2.46 +/- 1.04, P < 0.001), and the angles were significantly smaller (13.25 +/- 1.28 degrees vs. 24.11 +/- 11.0 degrees P < 0.001). During surgery the intramural portions of the coronary arteries appeared to be free of atherosclerotic plaques. Mean cross clamp time of patients with intramural coronary arteries was longer than that in control patients (58.86 +/- 19.65 vs. 48.29 +/- 16 68, P < 0.01). CONCLUSIONS: Major intramural coronary arteries can be diagnosed preoperatively by angiographic examination. Overlying myocardial bands play a protective role against coronary artery atherosclerosis.

Simultaneous hydatid cysts of both the right atrium and right ventricle.

Hydatid disease in both chambers of the heart is very rare. Mobile right atrial and right ventricular hydatid cysts were diagnosed incidentally in the etiologic work up for a transient ischemic attack in a 77-year-old man with a history of a hepatic hydatid cyst operation. Transthoracic echocardiography was very successful in the diagnosis of both hydatid cysts. Transesophagial echocardiography and computed tomography confirmed the diagnosis. Both right atrial and right ventricular hydatid cysts were removed under cardiopulmonary bypass to prevent morbidities and potentially fatal complications.

Delayed traumatic occlusion of the extracranial internal carotid artery after earthquake: report of two cases.

We report on two patients with head and neck injuries, who remained asymptomatic after the earthquake for 1 and 2 years, respectively. They developed late transient ischemic neurological signs and eventually presented with complete occlusion of the internal carotid artery. They made a good recovery with medical treatment. Focal cerebral ischemic symptoms may develop months or even years after the head or neck trauma, and internal carotid artery occlusion should be considered in differential diagnosis as a late complication.