Results of endovascular treatments of Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease involving the aortic bifurcation.

Objectives: The current study aims to report midterm results of patients treated with endovascular intervention, kissing stent, or covered endovascular reconstruction of the aortic bifurcation, for Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease involving the aortic bifurcation. Methods: Eighteen patients who have intermittent claudication or chronic limb threatening ischemia with Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease involving the aortic bifurcation enrolled to the study between January 2018 and January 2021. Kissing stents, Advanta V12 (Atrium, Getinge Group), were used in 13 patients, and the covered endovascular reconstruction of the aortic bifurcation technique was used in 4 patients to reconstruct the aortic bifurcation. The patients were followed for a median of 49 months (min. 2, max.58 months). Patency rates, mortality, morbidities, and reinterventions were recorded. Results: The mean age of the patients was 60.4 ± 10 years. Technical success was achieved in 94.4% of the patients, but one patient had to convert to open surgery. Primary patency rate of the remaining patients was 85.6% at 58 months. Target lesion revascularization rate was 11.7%. One patient had successful reintervention for in stent restenosis, and secondary patency rate was 93.3% at 58 months. Limb salvage rate was 84.6% during the follow-up. Two patients had myocardial infarction (11.1%) and one mortality (5.6%) occurred because of cerebrovascular event in the follow-up. Conclusions: Endovascular techniques can be used safely for reconstruction of the aortic bifurcation in Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease in selected patients who have high risk for open surgery. Covered endovascular reconstruction of the aortic bifurcation is the only technique that showed patency rates approaching open surgery in treatment of aortoiliac occlusive disease involving the aortic bifurcation to date. Although promising patency results were achieved with kissing-covered stents, long-term patency rates were still lower than those achieved with open surgery. Further randomized controlled studies comparing the long-term results of these techniques are needed.

Systemic inflammatory response during cardiopulmonary bypass: Axial flow versus radial flow oxygenators.

BACKGROUND: The objective of this study was to investigate the inflammatory effects of different oxygenator flow pattern types in patients undergoing coronary artery bypass graft surgery with cardiopulmonary bypass. METHODS: We designed this randomized, single-blind, prospective study of patients with coronary artery disease. We compared the systemic inflammatory effects of oxygenators with two types of flow: axial flow and radial flow. Therefore, we divided the patients into two groups: 24 patients in the axial group and 28 patients in the radial group. IL-1, IL-6, IL-10, and TNF-α were examined for cytokine activation leading to a systemic inflammatory reaction. The samples were collected at three different time intervals: T1, T2, and T3 (T1 was taken before cardiopulmonary bypass, T2 just 1 h after CPB onset, and T3 was taken 24 h after the surgery). RESULTS: There were no significant differences in demographic characteristics between the two groups. We observed that there were notably lower levels of humoral inflammatory response parameters (IL-1, IL-6, and TNF-α) in the radial flow oxygenator group than in the axial flow group at the specific sampling times. For IL-10, there was no significant difference for any time period. CONCLUSION: It might be advantageous to use a radial-flow-patterned oxygenator to limit the inflammatory response triggered by the oxygenators in cardiopulmonary bypass.

Efficacy and cost-effectiveness of cell saver usage in the repair of thoracic aortic aneurysms and dissections.

INTRODUCTION: A substantial amount of blood loss occurs during the open repair of aortic aneurysms or dissections. The aim of the present study is to determine the efficacy and cost-effectiveness of cell saver devices in blood conservation during the open repair of thoracic aortic pathologies. METHODS: The present study prospectively collected the data pertaining to 25 patients who underwent surgical management of thoracic aortic aneurysms or dissections using a cell saver (Group 1, n = 25). The volume and cost of transfusion and postoperative outcomes were compared with the second group of patients who underwent surgery without the use of cell savers in the previous year (Group 2, n = 25); the data pertaining to the same were retrospectively collected from the hospital records. The patient characteristics and categorical variables were compared using the x2 test and Fisher's exact test. Transfusion volume and costs were compared using the independent samples t-test and Mann-Whitney U test. RESULTS: The patients in both the groups displayed similar characteristics and risk factors. The total volume of allogenic red blood cell (p < 0.001) and total blood product (p = 0.01) transfusions were significantly lower in Group 1. The cost of red blood cell (p < 0.001) and total transfusions (p = 0.03) were lower in Group 1. The two groups displayed similar in-hospital morbidity and mortality rates. CONCLUSIONS: There was a significant association between the use of cell savers and the decreased need for red blood cell and total blood product transfusions. Considering the cost of the cell saver set, transfusion costs in the two groups were comparable.

Identification and characterization of a novel FBN1 gene variant in an extended family with variable clinical phenotype of Marfan syndrome.

Marfan syndrome (MFS) is a multi-systemic autosomal dominant condition caused by mutations in the gene (FBN1) coding for fibrillin-1. Mutations have been associated with a wide range of overlapping phenotypes. Here, we report on an extended family presenting with skeletal, ocular and cardiovascular clinical features. The 37-year-old male propositus, who had chest pain, dyspnea and shortness of breath, was first diagnosed based on the revised Ghent criteria and then subjected to molecular genetic analyses. FBN1 sequencing of the proband as well as available affected family members revealed the presence of a novel variant, c.7828G>C (p.Glu2610Gln), which was not present in any of the unaffected family members. In silico analyses demonstrated that the Glu2610 residue is part of the conserved DINE motif found at the beginning of each cbEGF domain of FBN1. The substitution of Glu2610 with Gln decreased fibrillin-1 production accordingly. Despite the fact that this variation appears to be primarily responsible for the etiology of MFS in the present family, our findings suggest that variable clinical expressions of the disease phenotype should be considered critically by the physicians.

Three Cases of Large-Diameter True Brachial and Axillary Artery Aneurysm and a Review of the Literature.

Aneurysms of the upper extremity mostly originate from trauma, mycotic lesions, thoracic outlet syndrome, previous arteriovenous fistulae, and atherosclerosis. True aneurysms of the brachial and axillary artery are encountered rarely. They can be diagnosed by simple physical examination as a pulsatile mass. However, most of these aneurysms remain asymptomatic until a complication occurs. The primary complication seen with the axillary or brachial artery is embolization. We report 3 large-diameter true brachial artery aneurysms extending to the axillary zone. One of the patients had distal digital emboli causing gangrenous lesions at the finger tips and the other 2 patients had pain and ischemic symptoms in the forearm. All underwent surgical repair. After excision of the aneurysmal segment, arterial continuity was ensured by interposition of a reversed saphenous vein in 2 patients and with a biological vascular graft in 1 patient. Although endovascular techniques are improving, most true brachial artery aneurysms are not anatomically suitable for interventional procedures. Open surgery still preserves its value.

Management of a patient with giant aneurysms in the popliteal and coronary arteries.

Coexistence of multiple peripheric arterial and coronary artery aneurysms of different sizes is extremely rare in young adults. We present a case of rare giant coronary aneurysm and concurrent giant left popliteal aneurysm treated with classical open repair.

Bentall Operation in a Patient With Severe Hemophilia A and Marfan Syndrome by Use of a Biologic Composite Graft.

We describe a patient with severe hemophilia A and Marfan syndrome who underwent an elective Bentall operation. Because of the severe hemophilia, anticoagulation could not be given postoperatively; thus, a biologic Valsalva conduit graft was used. During the procedure, factor VIII was given as a bolus dose just before incision, then by continous infusion intraoperatively to maintain the factor VIII activity level between 200% and 300%. Minimal postoperative bleeding occurred. The infusion was continued postoperatively at a lower dose until all chest tubes, pacing wires, and invasive catheters were removed. The patient was discharged on postoperative day 7 without adverse events.

Emergency surgical approach to device emboli due to migration of the atrial septal defect occluder.

INTRODUCTION: Atrial septal defect (ASD) transcatheter occlusion techniques are now established as the preferred method and have become an alternative to surgery under extracorporeal circulation. In this study, we aimed to present our emergency surgical approach to cases of device embolization due to migration of the atrial septal defect occluder. MATERIAL AND METHODS: Between June 2009 and June 2011, 6 patients underwent emergency operations due to device emboli secondary to migration of the transcatheter atrial septal defect occluder during the early period. Mean age was 25.5 years (15-45) and 3 of the patients were female (50%). The diagnosis was made via transthoracic echocardiography (TTE) preoperatively. RESULTS: All of these 6 patients underwent emergency operations. Mean postoperative intensive care unit (ICU) stay was 2.2 days and mean hospital stay was 6 days. No early or late postoperative mortality was seen. Mean postoperative follow-up time was 19.3 months (range: 5-28 months). Early- and late-period TTE examinations showed no residual interatrial shunting. One patient developed a right atrial thrombus in the postoperative 22(nd) month as a complication of long-term follow-up. He was treated with anticoagulant therapy for 6 months with complete resolution at the TTE. CONCLUSIONS: Transcatheter occlusion of secundum type ASD provides prominent clinical improvement, as well as a regression in dimensions of cardiac chambers. Nevertheless, this technique has drawbacks such as distal migration and residual shunts. Consequently, we think that unfavorable anatomy and device diameter are major issues in device migration. Oversizing also increases the migration risk.

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.

Surgical treatment of a giant external-iliac-vein aneurysm in a patient with a post-traumatic femoral arteriovenous fistula.

Iliac vein aneurysm is a rare vascular abnormality. It has been reported as a primary aneurysm of unknown cause, or, when a cause could be identified, as a secondary iliac vein aneurysm. Occasionally, iliac vein aneurysm develops in association with distal arteriovenous fistula. Although venous aneurysms occur most commonly in the neck and central thoracic veins, they also have been reported in the visceral veins and the extremities.Herein, we present the case of a 34-year-old man in whom a giant external-iliac-vein aneurysm was incidentally found during the investigation of a post-traumatic femoral arteriovenous fistula. The aneurysm was surgically resected, the iliac vein was reconstructed by means of lateral venorrhaphy, and the patient had an uneventful, complete recovery. We discuss the origin of the aneurysm and our choice of surgical techniques.

Surgical treatment of symptomatic coiling or kinking internal carotid artery.

Coiling of the artery is a rare morphologic entity most frequently described in the internal carotid artery. Herein we present two cases with symptomatic kinked internal carotid artery: one suffering from paresthesia of the right arm and speech disturbances and the other suffering from weakness of the left half of the body and speech disturbances. Both patients were treated surgically. None of the patients experienced any peri- or postoperative complications.

Bypass grafting for infrapopliteal occlusive disease with poor distal flow on angiography.

OBJECTIVE: We aimed to investigate whether limb-salvage bypass operation improves outcomes in patients with critical infrapopliteal ischemia and poor or no distal arterial flow on angiography. METHODS: Forty-nine patients with severe tibial and peroneal occlusive disease and poor distal arterial flow on angiography were included in this prospective study. The age ranged from 57 to 82 years in the surgical group and 63 to 80 in the medical group. Patients had class III or IV disease according to Fontaine classification. Preoperative arterial Doppler ultrasonography and arteriography were performed in all patients. The ankle-brachial index (ABI) was calculated preoperatively and postoperatively in all of the cases. Twenty-three patients underwent distal bypass operation. Other 26 patients were followed with medical therapy. The outflow distal anastomoses were performed on posterior tibial, dorsal pedal, anterior tibial, peroneal, and lateral plantar arteries. All patients were followed-up for 3 years and clinical outcomes were recorded. The statistical analyses were performed using unpaired t, Mann Whitney and Wilcoxon tests. RESULTS: There were 3 early and 2 late graft failures. Limb salvage rates were 84.2%, 84.2%, 73.7% in the surgical group, and 82.8%, 69.9%, 64.3% in the medical group respectively in 6 months, 1 year, and 3 years. According to statistical analysis; the levels of the amputations tend to be lower in the surgical group than in the medical group but it was not significant statistically. Surgical treatment reduced the amputation ratio (p<0.05) but medical therapy did not (p>0.05). The difference between preoperative mean ABI [0.26+/-0.06] and postoperative mean ABI [0.80+/-0.24] was significant (p<0.05). CONCLUSION: We think that limb-salvage bypass operation may be preferred for patients with critical limb ischemia and poor distal flow on angiography. Infrapopliteal bypass will provide limb salvage and a functional extremity.

Occlusive arterial disease after radiotherapy for testicular cancer: case report and review of the literature.

Radiation injury to arterial occlusion is a rare and late complication of radiotherapy. Numerous adverse reactions may occur secondary to radiation therapy. A well-known side effect is radiation-induced occlusive lesions and the enhancement of normally occurring atherosclerosis. We report a case of symptomatic right iliac and femoral artery occlusion after radiation therapy for carcinoma of the testis.

Off-pump coronary artery bypass surgery in patients with chronic renal failure.

OBJECTIVE: Patients with dialysis-dependent renal disease frequently present with coronary artery disease. These patients are considered to be at high risk for coronary artery bypass grafting. Therefore, off-pump coronary artery surgery may become a good option for these patients. Off-pump coronary artery bypass surgery in patients with dialysis-dependent renal failure was retrospectively reviewed in this study. METHODS: From March 2001 through May 2005, we performed off-pump coronary bypass grafting in 10 patients with dialysis-dependent renal failure. Coronary artery bypass grafting was performed on beating heart in all of the patients. The patients were evaluated for perioperative variables and postoperative outcomes. RESULTS: Mean age was 58.7+/-8.9 years with a range between 45 to 76 years. Eight of the patients were male and two were female. No perioperative and postoperative deaths or ischemic cardiac events were observed. Anginal symptoms of the patients were relieved during the postoperative period. Functional status of the patients was improved postoperatively. None of the patients needed revision due to hemorrhage. Mean distal anastomosis number was 1.8+/-0.6. Mean intensive care unit stay was 1.8+/-0.8 days and hospital stay was 5.3+/-0.9 days. CONCLUSION: Off-pump coronary artery bypass grafting can be performed with good clinical results. We believe that off-pump coronary revascularization is a good option in patients with dialysis-dependent renal failure.