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.

Effects of perioperative statin treatment on postoperative atrial fibrillation and cardiac mortality in patients undergoing coronary artery bypass grafting: a propensity score analysis.

AIM: To evaluate the effect of perioperative statin treatment on postoperative atrial fibrillation and cardiac mortality in patients undergoing coronary artery bypass grafting. METHODS: A total of 1890 patients who underwent isolated coronary artery bypass were analyzed retrospectively, of which 425 patients (22.4%) older than 70 were included in the study. The demographic properties, preoperative, operative and postoperative data and other medications of these patients were recorded. Continuous preoperative and postoperative atorvastatin therapy were received by 124 (29.17%) patients; 301 (70.82%) patients were matched to a control group (no-statin group). The two groups were matched by propensity score analysis in terms of atrial fibrillation development and cardiac mortality. RESULTS: Medical history, medical treatment, cardiovascular history, and operative characteristics demonstrated significant heterogeneity in both groups. Postoperative atrial fibrillation was similar in both groups. Before propensity score matching, the percentages of patients in postoperative atrial fibrillation with respect to Atorvastain-group and No-statin-group were 13.71 and 10.3 respectively; however, those were 13.71 and 14.51 after matching. In a multivariate regression analysis, five-vessel bypass (odds ratio OR, 2.354; 95% confidence interval CI, 0.99 to 5.57) was an independent predictor of postoperative atrial fibrillation in patients undergoing coronary artery bypass grafting. In-hospital mortality was higher in the Atorvastatin-group compared with the No-statin-group: 124 (8.9%) versus 301 (3.7%), respectively; p=0.027). CONCLUSION: Perioperative atorvastatin treatment is not found to be associated with reduced postoperative atrial fibrillation and cardiac mortality in patients undergoing isolated coronary artery bypass grafting above the age of seventy years.

Efficacy of chronic statin therapy on major cardiac events after coronary artery bypass grafting: low-dose versus high-dose.

AIM: To investigate whether chronic statin treatment after coronary artery bypass grafting (CABG) protects patients from major cardiac events and provides percutaneous coronary intervention (PCI) free survival. METHODS: A total of 232 patients with previous CABG and chronic statin therapy were selected retrospectively and were divided into two groups according to a dosage of atorvastatin per day, e. g., 20 mg or 40 mg. Groups were compared for the major cardiac events and freedom from PCI by Kaplan Meier analysis as the primary end point. Patency of grafts including left internal thoracic artery (LITA) and saphenous vein (SVG) and progression of non-grafted native vessel disease were also evaluated as secondary end points. RESULTS: Cardiac mortality, periprocedural myocardial infarction (MI), target vessel revascularization and percutaneous coronary intervention free survival were as follows: 2.9% versus 2.1% (p=1.000); 16.1% versus 21.1% (p=0.331); 56.93% versus 52.63% (p>0.005); 58.4% versus 63.2% (log-rank test; p= 0.347) in atorvastatin 20 mg and atorvastatin 40 mg groups, respectively. However, these results were not statistically significant between two groups (p>0.005). Patency of openness of grafts including LITA and SVG and progression of non-grafted native vessel disease were similar between groups (p=0.112, p=0.779, p=0.379 and p=0.663, respectively). CONCLUSION: Low-dose long-term statin treatment had similar outcomes on major cardiac events and identical rate of freedom from percutaneous coronary intervention after coronary artery bypass grafting compared with high-dose long-term statin treatment. It is better to start from low dose statin treatment after surgical interventions.

Impact of elevated serum estradiol/free testosterone ratio on male varicose veins in a prospective study.

OBJECTIVE: Although some studies indicate an association between increased levels of estradiol and varicose veins in women, the role of sex hormones on varicose veins have a question mark in men. METHODS: We investigated estradiol-2/free testosterone (E2/fT) ratio relationship on varicosity in 100 male patients dividing them into two groups. Group A (n = 46) had varicose veins with endocrinological problems, especially infertility, whereas group B (n = 54) also had varicose veins but no endocrinological problems. Venous blood samples were drawn from both groups in the morning to detect the levels of serum estradiol (E2), androstenedione, dehydroepiandrostenedione sulphate and free testosterone (fT). Patient history, physical examination, colour duplex ultrasound of both limbs and classification of CEAP were performed in both groups. Serum E2/fT ratio was calculated in correspondence with CEAP classification. CEAP classification is the varicosity classification, and it is concerned about the clinical class (C), etiology (E), anatomical distribution (A) and underlying pathophysiology (P). RESULTS: E2/fT ratio was significantly higher in group A (4.18 ± 0.54) compared with group B (2.98 ± 0.36). Moreover, there is a high correlation between serum E2/fT ratio and CEAP clinical classification in group A (4) compared with group B (2). CONCLUSION: Serum E2/fT ratio is associated with varicose veins in male patients.

Electron microscopic evaluation of internal thoracic artery endothelial morphology in diabetic coronary bypass patients.

BACKGROUND: Diabetes is a well- identified major risk factor for cardiovascular diseases. This study was performed to evaluate the effect of diabetes and impact of glycemic control on internal thoracic artery (ITA) morphology by electron microscopy. METHODS: Thirty patients scheduled for coronary artery bypass grafting were enrolled in this study. Samples of ITA were taken during the surgery for electron microscopic evaluation. Group I (n = 10) consisted of diabetics who have poor glycemic control (HbA1c > 7.5%), group II (n = 10) of well-regulated (HbA1c = 4.4% to 6.2%) diabetic patients, and group III (n = 10) of nondiabetic patients. Samples were prepared as ultrathin sections and an original semiquantitative method of scoring was applied to describe the morphologic changes of endothelium. Final scores were analyzed with analysis of variance and post hoc analysis. RESULTS: In group I large vacuoles, swollen mitochondria were seen in endothelial cells and subendothelial edema was prominent. Endothelia (2.5 ± 1.2), arterial wall (2.0 ± 0.0), and endothelial mitochondria (2.9 ± 1.3) scores of group I were significantly higher than the other 2 groups (p < 0.001). The samples of group II and group III did not show significant differences with each other. The correlation between HbA1c values and total endothelial scores statistically significant (r = 0.912; p < 0.001). CONCLUSIONS: There is a correlation between HbA1c values and morphologic changes of ITA graft. Uncontrolled diabetes is an important predictor of morphologic changes evidenced by the ultrastructural findings. These ultrastructural changes were not as prominent in the diabetes mellitus patients with well controlled metabolic statuses and patients without diabetes.

Single-centre experience with perioperative use of intraaortic balloon pump in cardiac surgery.

BACKGROUND: Intraaortic balloon pump (IABP) is frequently used in cardiac surgery in order to prevent or treat low cardiac output syndrome. Although being widely used and forming the first line therapy in these haemodynamically unstable patients despite maximal medication, optimal timing for IABP insertion is still discussed. This retrospective study evaluates hospital outcomes of patients receiving IABP at preoperative, intraoperative and postoperative periods during cardiac surgery. MATERIALS AND METHODS: Between 2006 and 2012, 2196 patients underwent open cardiac surgery in our centre. IABP was used in 121 (5.4%) patients. Nine patients had preoperative IABP insertion, 76 patients (62.8%) had intraoperative insertion to ease weaning from cardiopulmonary bypass, and 36 patients (29.8%) had postoperative insertion in the intensive care unit mainly due to refractory haemodynamic instability. Hospital outcomes of these 121 patients were analysed retrospectively. RESULTS: The majority of the patients were male (men 89, 73.6% and women 32, 26.4%; mean age was 65.9±11.5 years). Among the cohort 87 (71.9%) underwent isolated coronary artery bypass surgery (CABG) and the rest (34 patients, 28.1%) were operated for valve disease with/without CABG or for CABG with carotid endarterectomy, left ventricular aneurysm repair, post myocardial infarction ventricular septal defect or pathologies involving ascending aorta. The overall hospital mortality of the whole cohort was 27.3%. Mortality rates according to IABP timing were 33.3%, 19.7% and 41.7% for pre, intra and postoperative insertion, respectively. Logistic regression analysis identified female gender, low ejection fraction (<30%), complex surgery and postoperative insertion as risk factors for mortality. CONCLUSION: IABP insertion timing in cardiac surgery is crucial and many reports advocate early insertion since patient outcomes are poor for late insertions. This single centre study also confirms that the least favourable results are among patients with postoperative IABP insertion.

Impact of a large hemodialysis arteriovenous fistula: on myocardial protection during cardiopulmonary bypass.

Arteriovenous fistulae have a substantial impact on systemic hemodynamics, but their effect on cardiopulmonary bypass is not well understood. The left-to-right shunting of blood through an arteriovenous fistula can create flow problems during cardiopulmonary bypass. We present the case of a 59-year-old man with end-stage renal disease who underwent coronary artery bypass grafting. During surgery, a large brachiocephalic arteriovenous fistula provided excessive venous return to the heart, compromising the myocardial protection offered by cardiopulmonary bypass. We modified the venous cannulation from a 2-stage single cannula to a bicaval cannula and were then able to achieve cardioplegic arrest and myocardial protection with no further problems.

Protective effect of ambroxol on pulmonary function after cardiopulmonary bypass.

BACKGROUND: To evaluate whether ambroxol administered orally during the perioperative period has a protective effect against postoperative pulmonary dysfunction in on-pump coronary artery bypass surgery. METHODS: Fifty younger patients without known pulmonary disease were randomly assigned into 2 groups. In ambroxol group (n = 25), patients were given ambroxol for a week before and after the elective coronary artery bypass grafting. In control group (n = 25), placebo was given. Groups were compared with respect to pulmonary function tests (PFTs), lecithin/sphingomyelin (L/S) ratio in the bronchoalveolar lavage fluid, arterial blood gases, and incidence of perioperative morbidity. PFTs were performed before medication and repeated on the postoperative seventh day. Bronchoalveolar lavage fluid was obtained just before cardiopulmonary bypass and within the first postoperative hour. Room air arterial blood gases were checked before and 2 days after the operation. RESULTS: Postoperative lecithin/sphingomyelins were significantly lower than the preoperative values in both groups, but differences between the groups in either preoperative or postoperative measurements were not significant. Although preoperative PaO2 in both groups was similar, it was significantly lower in control group on postoperative second day (62.4 +/- 7.1 vs. 55.2 +/- 6.4 mm Hg, P < 0.05). In either groups, postoperative forced vital capacity and forced expiratory volume in 1 second were significantly lower than preoperative values with a more prominent decrease in control group. Perioperative morbidity was similar. CONCLUSIONS: In on-pump coronary artery bypass grafting, ambroxol improves postoperative PFTs and PaO2 levels without any significant clinical implication, and it exerts these effects possibly in ways other than surfactant modulation.

Effects of previously well-developed collateral vessels on left internal mammary artery graft flow after bypass surgery.

Transthoracic Doppler ultrasonography can assess left internal mammary artery patency and flow after coronary artery bypass grafting. We aimed to show, by transthoracic Doppler ultrasonography, the early effects upon left internal mammary artery graft flow of preoperative collateral vessels supplying the left anterior descending artery. Thirty-four consecutive patients undergoing coronary artery bypass were prospectively enrolled: 19 patients with collateral vessels supplying the left anterior descending were compared with 15 patients without collaterals. After bypass, end-diastolic velocity, mean velocity, flow volume, and ejection fraction were significantly greater, and the resistivity index was lower in patients with collateral vessels. The changes in velocities, volume, resistivity index, and pulsatility index were also found to be greater in patients with collateral vessels than in those without collaterals. Collateral vessels were the only factor affecting the changes in end-diastolic volume, mean velocity, flow volume, and resistivity index in multivariate analysis. Three factors affected postoperative left ventricular ejection fraction: collateral vessels, preoperative ejection fraction, and changes in left internal mammary flow volume. We conclude that patients with well-developed collaterals to the left anterior descending have better flow in the left internal mammary graft and more significant improvement in left ventricular function after coronary bypass. The flow volume of the mammary graft and the improvement of ventricular systolic functions after coronary bypass might be presumed with the presence of grade 2 or 3 preoperative collateral vessels.

Off-pump, in situ internal thoracic artery grafting: a durable treatment for single-vessel coronary artery disease.

BACKGROUND: The value of off-pump in situ left internal thoracic artery to left anterior descending coronary artery bypass grafting in single-vessel coronary artery disease was assessed by long-term angiographic and clinical data. METHODS: One-hundred three randomly selected patients (87 male, 16 female; mean age, 57.4 +/- 10.5 years) underwent postoperative angiographic control after an average postoperative period of 4.8 +/- 2.9 years (up to 8.2 years; a total of 490 patient-years). RESULTS: Fifty-five patients (52%) were asymptomatic, whereas 31 (30%) had anginalike chest pain. Ninety-seven patients (94.2%) were in New York Heart Association class I or II. Five-year angina-free survival was 81% +/- 5%. Of 103 left internal thoracic arteries assessed, 99 were patent (overall patency, 96.1%). All four cases having occluded grafts had mild native vessel stenoses (<80%) before operation. The patency rate was 99% +/- 1% at 3 years, and 93% +/- 4% at 5 years. The left ventricular segmental wall motion score of the left anterior descending coronary arterial distribution improved from 4.1 +/- 1.1 to 3.7 +/- 0.9 (p = 0.001). Consequently, 15 patients (15%) underwent secondary revascularization (11 interventional and 4 surgical) 4.8 +/- 2.1 years after the primary operation. The most frequent indication for interventional revascularization was atherosclerotic progression in systems other than left anterior descending artery. The cases with graft occlusion were treated surgically. Five-year freedom from interventional or surgical repeat revascularization was 91% +/- 4%. CONCLUSIONS: In addition to the well-documented safety and reliability, off-pump in situ left internal thoracic artery grafting is also a durable treatment for isolated left anterior descending artery disease, in both clinical and angiographic terms.

Off-pump coronary artery bypass grafting: long term angiographic results.

OBJECTIVE: Although short-term results of off-pump coronary artery bypass grafting are well documented, late postoperative data are still scarce. This report provides an analysis of late postoperative control angiograms. METHODS: 265 patients (231 males, 34 females; mean age: 54 +/- 10) underwent postoperative angiographic control, after an average postoperative period of 4.2 +/- 2.3 years (up to 9 years, a total of 1110 years). A total of 385 distal anastomoses on 258 internal mammary arteries (IMAs) and 127 saphenous vein grafts (SVGs) were evaluated. The primary operation was single bypass in 156 cases (62%), double bypass in 98 (34%), and triple or more bypass in 11 (4%). RESULTS: Out of 258 IMAs, 241 were patent (93%), while SVG patency was 65% with 82 patent grafts out of 127 (p < 0.0001). The patency in the lateral branches (62%) and right coronary system (64%) were similar. The variables associated with graft occlusion were hypercholesterolemia (p = 0.02), poor left ventricular performance (p = 0.03), reoperation (p = 0.01), target coronary vessel caliber less than 1.5 mm (p < 0.0001), poor native coronary vessel quality (p = 0.0003) and low-grade stenosis (p = 0.02). In the poor left ventricle group, the left ventricular segmental wall motion score was improved (p = 0.004). Consequently, 47 patients underwent secondary revascularization (35 PTCA and 12 CABG). The leading indication was native coronary artery disease progression, frequently in the circumflex system, followed by graft failure. The cases with native vessel disease progression were referred to PTCA/stenting, while those with LAD graft occlusion were treated surgically. CONCLUSIONS: Probably the best candidates for OPCAB are those having target vessels of good caliber and quality, and high-grade stenoses. Postoperative lipid-lowering therapy seems to be prudential.

Evaluation of flow characteristics of the left internal thoracic artery graft: perioperative color Doppler ultrasonography versus intraoperative free-bleeding technique.

From October 2000 through April 2001, we prospectively evaluated the flow characteristics of the left internal thoracic artery (LITA) graft in a homogenous group of 44 men with isolated severe proximal left anterior descending coronary artery stenosis who underwent elective coronary artery bypass grafting with cardiopulmonary bypass. We performed transthoracic color Doppler ultrasonography preoperatively and repeated this examination in each patient between the 5th and 7th postoperative days, obtaining cross-sectional area, total flow volume, diastolic velocity, systolic velocity, mean velocity, pulsatility index, and resistance index. These results were compared with those of the intraoperative free-bleeding technique. Good-quality Doppler images of the LITA were easily obtained with a combined supraclavicular-parasternal approach. After surgery, systolic flow velocity, pulsatility index, and resistance index decreased significantly, but diastolic flow velocity and mean flow velocity increased significantly. The intraoperative flow volume obtained by the free-bleeding technique (32.42 +/- 12.33 mL/min) was significantly less than both pre- and postoperative ultrasonographic values (42.22 +/- 10.77 mL/min and 45.36 +/- 19.52 mL/min, respectively). No significant difference was found when changes in LITA values were compared between patients with (n=19) and without (n=25) normal anterior wall motion. We conclude that color Doppler ultrasonography is a reliable noninvasive technique for preoperative evaluation of the LITA as a graft and for postoperative long-term follow-up of graft function. However the intraoperative free-bleeding technique is not reliable for flow-volume measurement due to anesthesia-related hemodynamic changes and vasospasm. Color Doppler can prevent useless LITA harvesting and decrease the need for postoperative LITA angiography.

Comparison of changes in diastolic functions after aortic valve replacement with freestyle stentless porcine xenografts in patients with restrictive and nonrestrictive physiology.

In this study, the effect of valve replacement on diastolic parameters was evaluated preoperatively and postoperatively at 3, 6, and 12 months by comparing diastolic parameters in patients after aortic valve replacement with freestyle stentless porcine xenografts for aortic stenosis. Depending on deceleration time (DT) and isovolumetric relaxation time (IVRT) with preoperative echocardiographic assessment, patients were divided into two groups: restrictive physiology (DT < or = 150 msec and IVRT < 100 msec, 20 patients), and nonrestrictive physiology (DT > 150 msec and IVRT > or = 100 msec, 27 patients). Although left ventricular mass index significantly decreased in both groups, improvement in DT, IVRT, and ejection fraction occurred only in patients with restrictive physiology. As a result, the patients with restrictive diastolic characteristics had more benefit than the patients with nonrestrictive physiology after aortic valve replacement.

Increased dispersion of refractoriness in patients with atrial fibrillation in the early postoperative period after coronary artery bypass grafting.

INTRODUCTION: Increased atrial effective refractory period (AERP) dispersion is well correlated with vulnerability to atrial fibrillation (AF). However, the preoperative electrophysiologic characteristics of atrial abnormalities that may play an important role in the development of AF postoperatively in patients with coronary artery bypass grafting (CABG) have not been investigated in detail. METHODS AND RESULTS: Fifty-six consecutive patients who underwent CABG were enrolled in this study. Eighteen patients (14 men and 4 women; mean age 57.7 +/- 5.2 years) with AF in the early postoperative period and 38 patients (28 men and 10 women; mean age 56.3 +/- 6.4 years) without AF were compared with regard to preoperative clinical, echocardiographic, angiographic, and electrophysiologic parameters. Preoperative PA interval and AERP dispersion values were higher (P < 0.05) in patients who developed AF in the early postoperative period. PA interval (P < 0.05, odds ratio = 1.64, 95% confidence interval 1.17-2.30), AERP in the high right atrium (AERP(HRA); P < 0.05, odds ratio = 0.94, 95% confidence interval 0.91-0.97), AERP in the right posterolateral atrium (AERP(RPL); P < 0.05, odds ratio = 0.79, 95% confidence interval 0.63-0.98), AERP in the distal coronary sinus (AERP(DCS); P < 0.05, odds ratio = 0.84, 95% confidence interval 0.74-1.02), and AERP dispersion (P < 0.001, odds ratio = 1.29, 95% confidence interval 1.12-1.47) were independently related to post-CABG AF in univariate analysis. Increases in preoperative PA interval and AERP dispersion were found to be associated with a high risk for development of post-CABG AF. CONCLUSION: AERP dispersion is a suitable electrophysiologic indicator for atrial vulnerability. The presence of increased preoperative AERP dispersion and PA interval may indicate patients at high risk for development of AF in the early postoperative period after coronary artery bypass grafting.

Coronary artery anomalies in adult patients.

BACKGROUND: Coronary artery anomalies are discovered in less than 1% of angiography series. Since the number of angiographies and coronary bypass operations are increasing significantly every day, these anomalies are of clinical importance. MATERIAL/METHODS: 58,023 coronary angiographies were performed in the cardiology clinic of our hospital from 1978 to 2001. Coronary artery anomalies were discovered in 257 of these cases (0.44%). The mean age of these patients was 51.9+/-11.4 years (18-82). 80% were male (n=207). RESULTS: The circumflex artery (CXA) was the most frequently involved vessel (51.1%). Coronary arteries originating from the pulmonary artery were not encountered in our series due to the natural history of the disease. In 54 patients with coronary artery fistulae, 18 (33.3%) were closed by operation. Perioperative mortality was 5.5%. Acquired coronary artery fistulae or aneurysms due to trauma or inflammatory diseases are completely different entities and beyond the scope of this article. In 76 patients, open heart surgery was required for additional lesions, 57 of which were coronary artery bypass grafts. CONCLUSIONS: Being usually asymptomatic, coronary artery anomalies are usually discovered incidentally in the adult population. These pathologies are important for practical purposes, especially for interventional cardiologists, radiologists and cardiac surgeons, who should be aware of these anatomical entities. LMCA originating from the right coronary system has been reported to result in sudden death and myocardial ischemia, so these mostly asymptomatic patients must be followed closely.