Detection of residual varicose veins with near infrared light in the early period after varicose surgery and near infrared light assisted sclerotherapy.

OBJECTIVES: Varicose veins that cannot be seen with the naked eye can be easily detected with Near Infrared (NIR) light. With a minimally invasive procedure performed with NIR light guided, the need for reoperation is reduced, while optimal treatment of venous insufficiency and symptoms is provided. In this study, the detection of residual varicose veins after varicose vein surgery using NIR light and the results of treatment of sclerotherapy were investigated. METHODS: In this retrospective study, treatment and clinical outcomes of patients' who underwent NIR light-guided foam sclerotherapy for Clinical-Etiology-Anatomy-Pathophysiology (CEAP) (C1, C2) stage residual varicose veins after surgical varicose treatment between 2014 and 2017 were examined. Data of patients who underwent foam sclerotherapy with NIR light were collected and analyzed. RESULTS: A total of 151 patients and 171 lower extremity varicose veins were treated with surgery. 55 (35.7%) of the patients were male, and 96 (62.3%) were female. Their age ranges from 20 to 64, with an average age of 45.38. 4 (2.6%) of the patients had phlebectomy. 137 of patients (90.7%) had ligation of perforated veins, phlebectomy, and great saphenous vein (GSV) stripping, 10 of patients (6.6%) had GSV stripping, perforating vein ligation, phlebectomy, and small saphenous vein (SSV) surgery. No residual leakage was observed in the controls of GSV, SSV, and perforating veins by duplex ultrasonography (DUS). In the first month after varicose surgery, an average of 1.64 ± 1.05 sessions of sclerotherapy was applied to patients with CEAP C1, C2 stage residual varicose veins. 70 patients had one session of sclerotherapy, 37 patients had two sessions of sclerotherapy, 20 patients had three sessions of sclerotherapy, and 11 patients had four sessions of sclerotherapy administrated. The need for complementary therapy was required for all female patients; 13 of the male patients did not require complementary sclerotherapy. While single-session sclerotherapy was applied to most male patients (32 (58.18%), 10 (18.18%) patients received two sclerotherapy sessions. After completing sclerotherapy, 7 (4.63%) patients had superficial venous thrombosis, and 13 (8.60%) patients had hyperpigmentation. CONCLUSION: Surgical treatment is a safe and effective technique in venous insufficiency. Nevertheless, residual varicose veins may remain, and these can be detected noninvasively with NIR light. Foam sclerotherapy with NIR light is a minimally invasive and safe treatment method for small residual varicose veins after the operation. We think that sclerotherapy with NIR light as a complementary treatment is a practical, reliable, and demanding treatment for clinical improvement, especially in female patients.

The Importance of Prognostic Nutritional Index in Predicting Acute Renal Failure After On-Pump Coronary Artery Bypass Operations in Patients with Insulin-Dependent Diabetes Mellitus.

BACKGROUND: After coronary artery bypass graft (CABG) operations, acute kidney injury (AKI) appears at 5-30% rates, and this rate increases even more in patients with diabetes mellitus (DM). Prognostic nutritional index (PNI) is known as a valuable parameter that affects cardiovascular surgery outcomes. In this current study, we aimed to investigate the importance of PNI value in predicting AKI after on-pump CABG operations in insulin-dependent diabetic patients. METHODS: A total of 254 consecutive patients with insulin- dependent diabetes who underwent on-pump CABG in our clinic between January 2016 and January 2020 retrospectively were included in this study. In the postoperative period, patients were registered as the renal failure group (Group 1), and those who did not develop renal failure were registered as Group 2. RESULTS: A total of 255 patients with DM were included in the study. There were 82 patients in Group 1 and 173 patients in Group 2. There was no difference between the groups, in terms of age, gender, smoking, and hyperlipidemia rates. Hypertension rate significantly was higher in Group 2 (P = .001). In multivariate logistic regression analysis, hypertension (OR: 1.226, 95% CI: 1.114-2.459, P = .026), need for inotropic support (OR: 1.128, 95% CI: 1.070-1.784, P = .033), increased blood product use (OR: 1.291, 95% CI: 1.112-2.156, P = .021) preoperative high creatinine (OR: 3.563, 95% CI: 2.497-5.559, P < .001), and PNI (OR: 1.327, 95% CI: 1.118-2.785, P = .012) were independent predictors of AKI. CONCLUSION: In our study, we determined PNI value as an independent predictor in predicting acute renal injury occurring after on-pump CABG operations in patients with insulin-dependent DM.

Prognostic nutritional index as a marker of mortality: an observational cohort study of patients undergoing cardiac surgery.

Nutritional problem of the patient is a valuable stiuation in patients undergoing surgery. In this study, we aimed to investigate the relationship between prognostic nutritional index (PNI) and postoperative in-mortality in patients undergoing cardiac surgery. 1003 patients undergoing on-pump cardiac surgery in our hospital between January 2016-January 2020 were included in this study retrospectively. Patients were divided into two groups based on in-hospital mortality, as survivors (Group I, n = 934) and non-survivors (Group II, n = 69). Their preoperative nutritional status was determined using the PNI. Compared to survivors, non-survivors were found to have a significantly higher mean age (62.5 ± 10.8 vs. 67.45 ± 10.1, P < 0.001) and significantly lower mean preoperative ejection fraction (51.6 ± 0.3 vs. 44.5 ± 1.2, P < 0.001). And combined cardiac surgery rate was significantly higher in non-survivors (P = 0.009). Also non-survivors had a significantly lower mean PNI compared to survivors (44.76 ± 7.63 vs. 48.34 ± 6.71, P < 0.001). Multivariate analysis Model 1 revealed that age (Odds ratio (OR): 1.756; 95% confidence interval (CI): 1.250-3.790, P = 0.029), intra-aortic balloon pump usage (OR: 2.252, 95% CI: 1.885-6.194, P < 0.001), combined cardiac surgery (OR: 0.542, 95% CI: 0.428-0.690, P = 0.041) and the PNI (OR: 0.639, 95% CI: 0.552-0.874, P = 0.021) were independent predictors of mortality. In Model 2, age >70 (OR: 2.437, 95% CI: 1.983-5.390, P = 0.005), LVEF <35% (OR: 1.945, 95% CI: 1.586-3.492, P = 0.012), IABP usage (OR: 1.365, 95% CI: 1.109-2.196, P = 0.001) and PNI (OR: 0.538, 95% CI: 0.492-0.791, P = 0.033) were determined as independent predictors for mortality. In on-pump cardiac surgery, postoperative mortality is significantly associated with preoperative low PNI, and PNI can be a useful and suitable parameter for preoperative risk evaluation.

Administration of perivascular cyanoacrylate for the prevention of cellular damage in saphenous vein grafts: an experimental model.

OBJECTIVE: The saphenous vein is the most commonly used graft in coronary artery bypass surgery, since no suitable arterial graft is available. However, the frequency of late graft failure is a cause for research into graft protection. The objective of this study was to investigate the effect of synthetic adhesive cyanoacrylate administration on the saphenous vein graft for preventing vascular damage due to internal pressure on the graft. METHODS: In this study we enrolled 20 volunteer subjects who had undergone coronary artery bypass surgery and who had excess saphenous vein grafts. Perivascular cyanoacrylate was administered to one of two saphenous vein grafts explanted from each patient. The other saphenous vein graft from each patient was not treated and was used as the control. A model of the arterial system was created using a saphenous vein cardiopulmonary bypass system. Circulation was maintained at 120 mmHg for 45 minutes. Afterwards, the grafts were subjected to histopathological examination. RESULTS: The cyanoacrylate group of grafts did not develop severe vascular damage compared with many instances of moderate and severe damage due to compression in the control group of grafts (p = 0.003). CONCLUSION: Perivascular administration of cyanoacrylate appeared to be successful in the prevention of early saphenous vein graft injury. No in vivo study has been performed to date to assess endothelial damage in the saphenous vein, in order to demonstrate the long-term effect of cyanoacrylate. Further investigations are needed in this regard.

Clinical and echocardiographic results of the Kalangos biodegradable tricuspid ring for moderate and severe functional tricuspid regurgitation treatment.

INTRODUCTION: The Kalangos Biodegradable Tricuspid Ring (Kalangos Biodegradable Tricuspid Ring®, Bioring SA, Lonay, Switzerland) is a biodegradable prothesis in the treatment of functional tricuspid regurgitation (FTR). In this study, we aimed to determine the clinical and echocardiographic results of this prosthesis for moderate and severe FTR treatment and compare this technique with the results of semicircular DeVega annuloplasty. MATERIALS AND METHODS: From January 2005 through January 2010 we retrospectively studied the data on 64 consecutive patients underwent annuloplasty procedures for FTR treatment. The patients were assigned to 2 groups: (1) Kalangos BTR annuloplasty was performed in 32 patients, and (2) Semicircular DeVega annuloplasty was performed in the 32 patients. All patients were evaluated clinically and by echocardiography preoperatively, at the end of the 1st week, 3rd and 6th month following surgery. RESULTS: No complications related to the prosthesis or the procedures within the follow-up period were recorded. At the follow-up period, systolic pulmonary arterial pressure and tricuspid valve area diameter were found to be significantly lower than the preoperative values in both groups (p < 0.0001). At the follow-up period residual tricuspid regurgitation and the Tei index (Myocardial performance index) was significantly lower in group 1 compared to group 2 (p < 0.05). Three-quarters of the annuloplasty ring had degraded in the postoperative 6-months period. DISCUSSION: We conclude that Kalangos BTR is an efficient and safe prosthesis with easy implantation technique for FTR treatment, with encouraging midterm results.

Alternative option in patients with multisegmental left anterior descending coronary artery disease for providing complete myocardial revascularization.

OBJECTIVES: The basic aim of surgical interventions in patients with coronary artery disease is to complete myocardial revascularization. In such patients, however, complementary revascularization techniques may require in patients with multisegmental left anterior descending disease. Among the different procedures, we performed an alternative option in patients with multisegmental lad disease for providing complete myocardial revascularization. METHODS: This study consists of retrospective analysis of consecutive eight patients between january 2008 and august 2013. In all patients, the surgical procedure consisted of standard aortic and right atrial cannulations followed by coronary artery bypass grafting with cardiopulmonary bypass. At the lesions of non-lad vessels distal anastomoses were performed with saphenous vein graft. After that lad arteriotomies were performed at the proximal and the distal segment of coronary stenosis, and a bridge was formed with a short segment valveless svg. The left internal mammary artery was anastomosed on the bridge. RESULTS: This innovative technique was performed successfully in all the patients. There were no morbidity and in-hospital mortality. At follow-up 1 year control, all the patients have no complications. In 2 patients, control angiogram showed a patent lima to a bridge anastomosis. CONCLUSIONS: Although our series has a small group population, we advocate that this is a safe, easy, and efficient technique for providing complete revascularization in multisegmental lad disease. This technique could be performed with the good result and easy implementation. It perfuses both the proximal and the distal segments of the multisegmental lad stenoses.

Preoperative usages of levosimendan in patients undergoing coronary artery bypass grafting.

OBJECTIVES: Levosimendan (LS) is a new inotropic drug which belongs to the group of drugs known as calcium sensitizers. It is different from other inotropic agents by its inotropic and vasodilatory actions without an increase in myocardial oxygen consumption and considered as a good choice in high-risk patients undergoing cardiac surgery. We aimed to investigate the proper time of the administration and the effect of prophylactic usage of LS in patients with low left ventricular ejection fraction (LVEF) undergoing coronary artery bypass grafting (CABG). METHODS: Forty patients who underwent isolated CABG with LVEF) less than 30% were evaluated retrospectively. Patients were divided into 3 groups according to the induction time of LS during different phases of the operation and compared to a non-LS control group. LS infusion (0.2 µg/kg/min) was applied 12 hours before the operation in Group 1 (G1) (n=10), after the induction of anaesthesia in Group 2 (G2) (n=10) and during the pump removal period in Group 3 (G3) (n=10) and non-LS control group 4 (G4) (n=10). Demographic data, operative characteristics, hemodynamic parameters and serum lactate, troponin, creatinine levels were compared between groups before and after LS treatment during pre and postoperative period. Data were evaluated by Fisher exact, Kruskal-Wallis, Mann-Whitney U, Chi-square and Wilcoxon rank tests. RESULTS: We found that the duration of tracheal intubation, the intensive care unit stay and the hospital stay were significantly decreased in G1 and G2 when compared to the patients in G3 and G4. During postoperative period, in G1 and G2 one (10%) patient from each required intraaortic balloon pump (IABP), while in G3 two (20%) patients and in G4 five (50%) patients required IABP. Cardiac index (CI) was significantly increased in all groups from baseline to intensive care unit (ICU)1h and ICU24h. When groups compared each other significant increase was found in G1-G4 (p=0.001) and G2-G4 (p=0.007) at ICU1h. There was a significant increase in % EF especially in G1-G4 (p=0.011) and G2-G4 (p=0.007) at ICU1h. Systemic vascular resistance index significantly decreased in G1 and G2 in comparison to G3 and G4. However there was no significant decrease in pulmonary capillary wedge pressure of all 4 groups before and after LS. There was a significant decrease in mean pulmonary arterial pressure in G1 and G2 according to G4. Compared with the other groups preoperatively LS-treated patients (G1 and G2) had lower postoperative troponin I, serum lactate and creatinine concentrations. CONCLUSIONS: Our study shows that the elective preoperative initiation of LS especially 12 hours before the operation onset is associated with better improvement on cardiac functions as well as with lower mortality and complication rates, lower use of additional inotropic and vasopressor drugs, less need for intra-aortic balloon pump support and shorter length of stay in the ICU in patients with high perioperative risk or compromised left ventricular function. As a result, patients who received an infusion of LS 12 hours before surgery showed an evidence of less myocardial damage which suggested the preconditioning effect of the drug.

Surgical embolectomy for acute massive pulmonary embolism.

OBJECTIVE: Acute massive pulmonary embolism (PE) is associated with significant mortality rate despite diagnostic and therapeutic advances. The aim of this study was to analyze our clinical outcomes of patients with acute massive PE who underwent emergency surgical pulmonary embolectomy. METHODS: This retrospective study included 13 consecutive patients undergoing emergency surgical pulmonary embolectomy for acute massive PE at our institution from March 2000 to November 2013. The medical records of all patients were reviewed for demograhic and preoperative data and postoperative outcomes. All patients presented with cardiogenic shock with severe right ventricular dysfunction confirmed by echocardiography, where 4 (30.8%) of the patients experienced cardiac arrest requiring cardiopulmonary resuscitation before surgery. RESULTS: The mean age of patients was 61.8 ± 14 years (range, 38 to 82 years) with 8 (61.5%) males. The most common risk factors for PE was the history of prior deep venous thrombosis (n = 9, 69.2%). There were 3 (23.1%) in-hospital deaths including operative mortality of 7.7% (n = 1). Ten (76.9%) patients survived and were discharged from the hospital. The mean follow-up was 25 months; follow-up was 100% complete in surviving patients. There was one case (7.7%) of late death 12 months after surgery due to renal carcinoma. Postoperative echocardiographic pressure measurements demonstrated a significant reduction (P < 0.001). At final follow-up, all patients were in New York Heart Association class I and no readmission for a recurrent of PE was observed. CONCLUSION: Surgical pulmonary embolectomy is a reasonable option and could be performed with acceptable results, if it is performed early in patients with acute massive PE who have not reached the profound cardiogenic shock or cardiac arrest.

Acute mesenteric ischemia after cardiac surgery: an analysis of 52 patients.

OBJECTIVE: Acute mesenteric ischemia (AMI) is a rare but serious complication after cardiac surgery. The aim of this retrospective study was to evaluate the incidence, outcome, and perioperative risk factors of AMI in the patients undergoing elective cardiac surgery. METHODS: From January 2005 to May 2013, all patients who underwent cardiac surgery were screened for participation, and patients with registered gastrointestinal complications were retrospectively reviewed. Univariate analyses were performed. RESULTS: The study included 6013 patients, of which 52 (0.86%) patients suffered from AMI, 35 (67%) of whom died. The control group (150 patients) was randomly chosen from among cases undergoing cardiopulmonary bypass (CPB). Preoperative parameters including age (P = 0.03), renal insufficiency (P = 0.004), peripheral vascular disease (P = 0.04), preoperative inotropic support (P < 0.001), poor left ventricular ejection fraction (P = 0.002), cardiogenic shock (P = 0.003), and preoperative intra-aortic balloon pump (IABP) support (P = 0.05) revealed significantly higher levels in the AMI group. Among intra- and postoperative parameters, CPB time (P < 0.001), dialysis (P = 0.04), inotropic support (P = 0.007), prolonged ventilator time (P < 0.001), and IABP support (P = 0.007) appeared significantly higher in the AMI group than the control group. CONCLUSIONS: Prompt diagnosis and early treatment should be initiated as early as possible in any patient suspected of AMI, leading to dramatic reduction in the mortality rate.

Giant cardiac hydatid cyst in the interventricular septum protruding to right ventricular epicardium.

Cardiac hydatid cyst is a rare condition, and the location of a hydatid cyst in the interventricular septum is exceptional. A 54-year-old female was admitted to our hospital with complaints of chest pain, shortness of breath and malaise. Transthoracic echocardiography defined a cystic mass lesion of 50 × 59 mm originating from apex of the heart protruding into and compressing the interventricular septum. The cyst was excised surgically and the patient was discharged on the 8th postoperative day without symptoms. In our case, localization of the cystic mass was within interventricular septum which is an uncommon site. It limited both ventricular volumes significantly. In addition, this cyst was extensively protruding to the right ventricular epicardium.

Effects of temporary vascular occluder poloxamer 407 gel on the endothelium.

BACKGROUND: Coronary occlusion techniques during OPCAB may lead to an endothelial damage to the target vessel. The adverse effects of these techniques are well-known, and researches have been trying to find out new materials to occlude the coronary artery without an endothelial damage. In the present study, we investigate to the endothelial damage in the rat aorta which is occluded by Poloxamer 407 gel. METHODS: Forty-five rats were randomized in three groups: (1) segment of the aorta was occluded with Poloxamer 407 gel in P 407 group; (2) segment of the aorta was occluded with microvascular clamp in MV clamp group; and (3) no onclusion was available in the Control group. The rats were sacrificed of observation, and a 15mm segment of the aorta was obtained as a specimen. Integrity of the endothelial lining was observed with a scanning electron microscopy. RESULTS: Scanning electron microscopy revealed a statistically significant difference among the 3 groups (p<0,001) using the SPSS 13.0 test. No difference was found between the Control group and the P 407 group (p=0,059). The differences between MV clamp-Control group (p<0,001) and MV clamp-P 407 group were statistically significant (p<0,002). CONCLUSIONS: We suggest that Poloxamer 407 gel occlusion may be a safer and more effective method compared to the microvascular clamp occlusion.

Nitinol thermoreactive clips for secondary sternal closure in cases of noninfective sternal dehiscence.

Postoperative sternal dehiscence is a potentially catastrophic sequela to median sternotomy that can cause not only chest-wall discomfort and pulmonary dysfunction but infection, both superficial and mediastinal. Nitinol thermoreactive clips use a novel material in the treatment of sternal dehiscence. We sought to determine whether the use of these clips is an effective remedy for noninfective sternal dehiscence. From January 2008 through December 2011, we retrospectively studied the data on 10 patients whose sternums had been closed with nitinol thermoreactive clips after the development of noninfective sternal dehiscence. Diagnosis was made on the bases of clinical criteria, chest radiography, and microbiological investigation. There was no control group. No procedure-related sequelae occurred. There was no recurrent sternal instability and dehiscence, sternal-related hemorrhage, superficial wound infection, or mediastinal infection. We believe that the use of nitinol thermoreactive clips is a safe, easy, and efficient method of secondary sternal closure for noninfective sternal dehiscence.